Distribution of Gestational Age for Infants Who Survived to Age 1 Year and Infants Who Died before Age 1 Year

Data Source: National Vital Statistics System, Linked Birth and Infant Death Data.

Source: Centers for Disease Control and Prevention: Percentage Distribution of Gestational Age in Weeks for Infants Who Survived to Age 1 Year and Infants Who Died Before Age 1 Year — National Vital Statistics System, United States, 2014

Prevalence of High-Risk Genital HPV among Adults

Notes: Among adults 18 to 59 years of age.
1 Percentage for men is significantly higher than women.
2 Percentage is significantly different from non-Hispanic Asian, all, men, and women.
3 Percentage is significantly different from non-Hispanic white, all, men, and women.
4 Percentage is significantly different from non-Hispanic black, all, men, and women.
HPV is human papillomavirus. High-risk genital HPV means tested positive to one or more of the 14 high-risk HPV types (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, or 68) from a penile or vaginal swab sample. Penile samples were available only for 2013–2014, so all results presented were limited to that cycle.

Data Source: NCHS, National Health and Nutrition Examination Survey, 2013–2014.

Source: Centers for Disease Control and Prevention/National Center for Health Statistics: Prevalence of HPV in Adults Aged 18–69: United States, 2011–2014

Indian Health Service Patient Population, by Area

Notes: Figures are from 2014. The Albuquerque, Nashville, and Oklahoma City area offices oversee facilities in Texas. The Alaska, California, and Tucson areas do not have any federally operated IHS facilities.

Data Source: Indian Health Service; Map Resources (map).

Source: U.S. Government Accountability Office: Indian Health Service: Actions Needed to Improve Oversight of Quality of Care

Infant Mortality Rates for the Leading Causes of Infant Death

Notes: SIDS is sudden infant death syndrome. For each cause of death, the change in the rate from 2005 to 2014 is statistically significant (p < 0.05), but the change from 2013 to 2014 is not statistically significant.

Data Source: NCHS, National Vital Statistics System.

Source: Centers for Disease Control and Prevention/National Center for Health Statistics: Trends in Infant Mortality in the United States, 2005-2014

Widespread Gains in Access to Health Care, 2013-2015

Notes: For this exhibit, we count the District of Columbia as a state. “Improved” or “worsened” refers to a change between 2013 and 2015 of at least 0.5 standard deviations. “Little or no change” includes states with changes of less than 0.5 standard deviations as well as states with no change or without sufficient data to assess change. “Adults with a usual source of care” is an indicator in the Scorecard’s Prevention and Treatment dimension; it is included here because having a regular health care provider is associated with better access to care.

Data Source: Uninsured: U.S. Census Bureau, 2013 and 2015 1-Year American Community Surveys. Public Use Micro Sample (ACS PUMS). Cost Barriers, Doctor Visit, and Usual Source of Care: 2013 and 2015 Behavioral Risk Factor Surveillance System (BRFSS).

Source: The Commonwealth Fund: Aiming Higher: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition

Prevalence of Low HDL Cholesterol among Adults

Notes: 1 Significantly different from subgroup that did not meet physical activity guidelines.
2 Significantly different from women in the same group.
3 Overall total of low HDL prevalence was 19.0%.
HDL is high-density lipoprotein. Low HDL cholesterol is less than 40 mg/dL based on laboratory measurement. Data are age-adjusted by the direct method to the 2000 U.S. Census population, using age groups 20–39, 40–59, and 60 and over.

Data Source: NCHS, National Health and Nutrition Examination Survey, 2011–2014.

Source: Centers for Disease Control and Prevention/National Center for Health Statistics: Prevalence of Low High-density Lipoprotein Cholesterol Among Adults, by Physical Activity: United States, 2011–2014

Adults Who Were Up to Date with Cancer Screening, by Test

Notes: Abbreviation: CRC = colorectal cancer.
The U.S. Preventive Services Task Force (USPSTF) recommends mammography within 2 years for women aged 50–74 years.
USPSTF recommends Papanicolaou (Pap) test within 3 years for women aged 21–65 years without hysterectomy, or Pap test with human papillomavirus test within 5 years for women aged 30–65 years without hysterectomy. To account for changing screening recommendations over time for cervical cancer for women aged 21–65 years without hysterectomy, only trends for Pap test within 3 years for women aged 21–65 years without hysterectomy were assessed; Pap test data for 2003 are missing.
The USPSTF recommends three options for CRC screening: 1) fecal occult blood test within 1 year; 2) sigmoidoscopy within 5 years and fecal occult blood test within 3 years; or 3) colonoscopy within 10 years for respondents aged 50–75 years.

Data Source: National Health Interview Survey.

Source: Centers for Disease Control and Prevention: Cancer Screening Test Use — United States, 2015

ED Visits for Injury and Illness among Older Adults, by Age

Notes: 1 Linear trend is significant based on a weighted least-squares regression test (p < 0.05).
Abbreviation: ED, emergency department.
Among adults 65 years of age and older. Estimates are based on 2-year averages. Visit rates are based on the July 1, 2012 and July 1, 2013 sets of estimates of the civilian noninstitutionalized population developed by the U.S. Census Bureau’s Population Division.

Data Source: NCHS, National Hospital Ambulatory Medical Care Survey, 2012–2013.

Source: Centers for Disease Control and Prevention/National Center for Health Statistics: Emergency Department Visits for Injury and Illness Among Adults Aged 65 and Over: United States, 2012–2013

Prevalence of Heart Disease, Stroke, and Hypertension, by Family Income

Notes: Among adults. Data are from 2015 and are age adjusted.
Includes persons who reported a dollar amount or who would not provide a dollar amount but provided an income interval. “Heart disease” includes coronary heart disease, angina, heart attack, or any other heart condition or disease. People classified as hypertensive were told on two or more different visits that they had hypertension or high blood pressure.

Data Source: Centers for Disease Control and Prevention (CDC), National Center for Health Statistics, Summary Health Statistics. Available at: http://www.cdc.gov/nchs/nhis/shs.htm.

Source: Peterson-Kaiser Health System Tracker: What do we know about cardiovascular disease spending and outcomes in the United States?

Private-Sector Employees Enrolled in Employer-Sponsored Health Insurance

Notes: Denominator: within each category, all employees in establishments. State expanded Medicaid coverage during the period 2010 through 2015.

Data Source: Center for Financing, Access, and Cost Trends, AHRQ, Medical Expenditure Panel Survey Insurance Component, private-sector establishments, 2008–2015.

Source: Agency for Healthcare Research and Quality/Medical Expenditure Panel Survey: Trends in Enrollment, Offers, Eligibility and Take-Up for Employer-Sponsored Insurance: Private Sector, by State Medicaid Expansion Status, 2008-2015

New HIV Diagnoses, by Race and Ethnicity

Data Source: CDC. HIV Surveillance Report, Diagnoses of HIV Infection in the United States and Dependent Areas, 2015, Vol. 27; November 2016. HIV diagnosis data are preliminary estimates from 50 states, the District of Columbia, and 6 U.S. dependent areas. KFF. State Health Facts; accessed January 2017.

Source: Kaiser Family Foundation: Black Americans and HIV/AIDS: The Basics

ED Visits Related to Suicidal Ideation, by Age and Income

Notes: Among adults. Income represents community-level income based on the patient’s ZIP Code of residence.
Abbreviation: ED, emergency department.

Data Source: Agency for Healthcare Research and Quality (AHRQ), Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project (HCUP), Nationwide Emergency Department Sample (NEDS), 2006, 2010, and 2013.

Source: Agency for Healthcare Research and Quality/Healthcare Cost and Utilization Project: Emergency Department Visits Related to Suicidal Ideation, 2006-2013

Medicaid Provider Payment Levels Relative to Medicare Payments

Notes: The Medicaid-to-Medicare fee index measures each state’s physician fees relative to Medicare fees in each state. The Medicaid data are based on surveys sent by the Urban Institute to the 49 states and DC that have a fee-for-service (FFS) component in their Medicaid programs. These fees represent only those payments made under FFS Medicaid.
*Tennessee does not have a FFS program.

Data Source: Stephen Zuckerman, Laura Skopec, and Kristen McCormack, “Reversing the Medicaid Fee Bump: How Much Could Medicaid Physician Fees for Primary Care Fall in 2015?,” Urban Institute, December 2014.

Source: Kaiser Family Foundation: Current Flexibility in Medicaid: An Overview of Federal Standards and State Options

Physician Office Visits for ADHD among Children

Notes: 1 The visit rate for boys is significantly different (p < 0.05) from the rate for girls, based on a two-tailed t test.
Among children 4-17 years of age. Estimates are based on 2-year averages. Attention deficit/hyperactivity visits have a principal diagnostic code of ICD–9–CM 314.00 or 314.01. Visit rates are based on the July 1, 2012, and July 1, 2013, set of estimates of the civilian noninstitutionalized population of the United States, as developed by the Population Division, U.S. Census Bureau.

Data Source: NCHS, National Ambulatory Medical Care Survey, 2012–2013.

Source: Centers for Disease Control and Prevention/National Center for Health Statistics: Physician Office Visits for Attention-deficit/Hyperactivity Disorder in Children and Adolescents Aged 4–17 Years: United States, 2012–2013

Women of Reproductive Age Who Had Out-of-Pocket Spending on Oral Contraceptive Pills

Notes: Share of women age 15-44 with health coverage from a large employer who have any out-of-pocket spending on oral contraceptive pills, 2004-2014.

Data Source: Kaiser Family Foundation analysis of Truven Health Analytics MarketScan Commercial Claims and Encounters Database, 2004-2014.

Source: Kaiser Family Foundation: The Future of Contraceptive Coverage

Potentially Excess Deaths in Nonmetropolitan and Metropolitan Areas

Notes: Figure shows five leading causes of death. For each age group and cause, the death rates of the three states with the lowest rates during 2008−2010 (benchmark states) were averaged to produce benchmark rates. Potentially excess deaths were defined as deaths among persons aged < 80 years in excess of the number that would be expected if the age group–specific death rates of the benchmark states occurred across all states.
Nonmetropolitan and metropolitan areas were identified using the Office of Management and Budget’s 2013 county-based classification scheme. (Source: Office of Management and Budget, White House. Revised delineations of metropolitan statistical areas, micropolitan statistical areas, and combined statistical areas, and guidance on uses of the delineations of these areas. Washington, DC: Office of Management and Budget; 2013. https://www.whitehouse.gov/sites/default/files/omb/bulletins/2013/b13-01.pdf)

Data Source: National Vital Statistics System, United States, 2014.

Source: Centers for Disease Control and Prevention: Leading Causes of Death in Nonmetropolitan and Metropolitan Areas — United States, 1999–2014

Smoking Cessation among Adult Smokers

Notes: Change based on linear and quadratic trend analyses using logistic regression models controlling for sex, race/ethnicity, and age, p < 0.05. There was no change for “interested in quitting,” a quadratic trend for “made past-year quit attempt,” a linear trend for “recent smoking cessation,” a quadratic trend for “received advice to quit from health professional,” and a quadratic trend for “used counseling and/or medication.”
Status definitions:
Interested in quitting: current smokers who reported that they wanted to stop smoking completely.
Made past-year quit attempt: current smokers who reported that they stopped smoking for > 1 day in the past 12 months because they were trying to quit smoking and former smokers who quit in the past year.
Recent smoking cessation: former smokers who quit smoking for ≥ 6 months in the past year, among current smokers who smoked for ≥ 2 years and former smokers who quit in the past year.
Received advice to quit from health professional: received advice from a medical doctor, dentist, or other health professional to quit smoking or to quit using other kinds of tobacco, among current and former cigarette smokers who quit in the past 12 months. The analysis was limited to current and former cigarette smokers who had seen a doctor or other health professional in the past year.
Used counseling and/or medication: for 2010 and 2015, used one-on-one counseling, a stop smoking clinic, class, or support group, and/or a telephone help line or quitline; and/or the nicotine patch, nicotine gum or lozenge, nicotine-containing nasal spray or inhaler, varenicline (U.S. trade name Chantix) and/or bupropion (including trade names Zyban and Wellbutrin) in the past year among current smokers who tried to quit in the past year or used when stopped smoking among former smokers who quit in the past 2 years. For 2005, the list included a nicotine tablet and excluded varenicline, as it was not approved by the Food and Drug Administration until 2006. For 2000, the list included a stop smoking program and excluded a stop smoking class or support group, nicotine lozenge (not approved by the Food and Drug Administration until 2002), and varenicline.

Data Source: National Health Interview Survey, 2000–2015.

Source: Centers for Disease Control and Prevention: Quitting Smoking Among Adults — United States, 2000–2015

Percent of Selected Populations with Medicaid Coverage

Notes: FPL is Federal Poverty Level. The FPL was $20,160 for a family of three in 2016.

Data Source: Kaiser Commission on Medicaid and the Uninsured (KCMU) analysis of 2016 CPS/ASEC Supplement; Birth data – Kaiser Family Foundation Medicaid Budget Survey, 2016 (median rate shown); Medicare data – Medicare Payment Advisory Commission, Data Book: Beneficiaries Dually Eligible for Medicare and Medicaid (January 2016), 2011 data; Disabilities – KCMU Analysis of 2015 NHIS data; Nonelderly with HIV – 2009 CDC MMP; Nursing Home Residents – 2012 OSCAR data.

Source: Kaiser Family Foundation: Medicaid Pocket Primer

Adults Who Are Very Worried about Medical Costs, by Home Ownership

Notes: Error bars indicate 95% confidence intervals.
Based on the response “very worried” to the question on sample adult questionnaire, “How worried are you right now about not being able to pay medical costs for normal healthcare?“ Other categories included: “Moderately worried,” “Not too worried,” “Not worried at all.” Unknowns were included in the denominators when calculating percentages.
Home ownership was defined by family respondent’s response to question on family core questionnaire, “Is this house/apartment owned or being bought, rented, or occupied by some other arrangement by [you/or someone in your family]?“
Estimates are based on household interviews of a sample of the noninstitutionalized, U.S. civilian population and are derived from the National Health Interview Survey family core and sample adult components.

Data Source: National Health Interview Survey, 2015 data. http://www.cdc.gov/nchs/nhis.htm.

Source: Centers for Disease Control and Prevention: Percentage of Adults Aged ≥18 Years Who Are Very Worried about Medical Costs, by Home Ownership and Age Group — National Health Interview Survey, United States, 2015

Rates of Hospital-Acquired Conditions

Notes: HAC is hospital-acquired condition.

Data Source: AHRQ National Scorecard Estimates from Medicare Patient Safety Monitoring System, National Healthcare Safety Network, and Healthcare Cost and Utilization Project.

Source: Agency for Healthcare Research and Quality: National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data From National Efforts To Make Health Care Safer

Federal Spending on the Major Health Care Programs

Notes: CHIP = Children’s Health Insurance Program.
a. Net Medicare spending (includes offsetting receipts from premium payments by beneficiaries, recoveries of overpayments made to providers, and amounts paid by states from savings on Medicaid’s prescription drug costs).
b. Spending to subsidize health insurance purchased in the marketplaces established under the Affordable Care Act and provided through the Basic Health Program and spending to stabilize premiums for health insurance purchased by individual people and small employers.

Data Source: Congressional Budget Office (as of August 2016).

Source: Congressional Budget Office: Options for Reducing the Deficit: 2017 to 2026

Opioid-Related Inpatient Stays and ED Visits

Notes: Abbreviation: ED, emergency department.

Data Source: Agency for Healthcare Research and Quality (AHRQ), Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project (HCUP), HCUP Fast Stats, Opioid-Related Hospital Use (http://www.hcup-us.ahrq.gov/faststats/landing.jsp) based on the HCUP National (Nationwide) Inpatient Sample (NIS) and the HCUP Nationwide Emergency Department Sample (NEDS).

Source: Agency for Healthcare Research and Quality/Healthcare Cost and Utilization Project: Opioid-Related Inpatient Stays and Emergency Department Visits by State, 2009-2014

ED Visits Involving Mental and Substance Use Disorders

Notes: Abbreviations: ED, emergency department; SUD, substance use disorder.

Data Source: Agency for Healthcare Research and Quality (AHRQ), Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project (HCUP), Nationwide Emergency Department Sample (NEDS), 2006–2013.

Source: Agency for Healthcare Research and Quality/Healthcare Cost and Utilization Project: Trends in Emergency Department Visits Involving Mental and Substance Use Disorders, 2006–2013

Health Status of American Indians and Alaska Natives

Notes: * Indicates statistically significant difference from White population at the p < 0.05 level. Whites and AIANs are non-Hispanic.

Data Source: Kaiser Family Foundation analysis of CDC, National Health Interview Survey, 2015, Kaiser Family Foundation analysis of CDC, Behavioral Risk Factor Surveillance System, 2015 and Results from the 2015 National Survey on Drug Use and Health: Detailed Tables, http://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs-2015/NSDUH-DetTabs-2015/NSDUH-DetTabs-2015.htm#toc

Source: Kaiser Family Foundation: Health and Health Care for American Indians and Alaska Natives (AIANs)

Persons Who Had Directly Purchased Private Health Insurance, by Poverty Level

Notes: Among persons under 65 years of age. Private health insurance that was originally obtained through direct purchase or other means not related to employment was considered directly purchased coverage. Data are based on household interviews of a sample of the civilian noninstitutionalized population.

Data Source: NCHS, National Health Interview Survey, 2011–2013, Family Core component.

Source: Centers for Disease Control and Prevention/National Center for Health Statistics: Quarterly Estimates of Directly Purchased Private Health Insurance Among Persons Under Age 65: United States, 2011–2013

Use of Alcohol and Marijuana in the Past Month, by Age

Note: Binge alcohol use is defined as drinking five or more drinks (for males) or four or more drinks (for females) on the same occasion (i.e., at the same time or within a couple of hours of each other) on at least 1 day in the past 30 days.

Data Source: Center for Behavioral Health Statistics and Quality. (2016). Results from the 2015 National Survey on Drug Use and Health: Detailed tables. Rockville, MD: Substance Abuse and Mental Health Services Administration.

Source: U.S. Department of Health and Human Services: Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health

Breakdown of the Uninsured Population

Notes: Among nonelderly individuals. Data are from 2015. The U.S. Census Bureau’s poverty threshold for a family with two adults and one child was $19,078 in 2015. Data may not total 100% due to rounding.

Data Source: Kaiser Family Foundation analysis of the 2016 ASEC Supplement to the CPS.

Source: Kaiser Family Foundation: Who is Impacted by the Coverage Gap in States that Have Not Adopted the Medicaid Expansion?

Distribution of Population and Health Care Expenditures, by Age Group

Note: Percentages may not add to 100 because of rounding.

Data Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, Household Component, 2014.

Source: Agency for Healthcare Research and Quality/Medical Expenditure Panel Survey: Concentration of Health Expenditures in the U.S. Civilian Noninstitutionalized Population, 2014

Annual Rate of Tobacco-Related Cancer Cases, by State

Notes: For 2009 to 2013. Per 100,000 persons, age-adjusted to the 2000 U.S. standard population.
Tobacco-related cancers include oral cavity and pharynx; esophagus; stomach; colon and rectum; liver; pancreas; larynx; lung, bronchus, and trachea; cervix; kidney and renal pelvis; urinary bladder; and acute myeloid leukemia.

Data Source: National Program of Cancer Registries and Surveillance, Epidemiology, and End Results Program.

Source: Centers for Disease Control and Prevention: Disparities in Tobacco-Related Cancer Incidence and Mortality — United States, 2004–2013

Firms Offering Health Benefits to Same-Sex Spouses, by Firm Size

Notes: Among firms offering spousal benefits.
“Not encountered” refers to firms where no workers requested domestic partner benefits and there is no corporate policy on coverage for same-sex spouses. Eighty-nine percent of small firms (3-199 workers) offering health benefits and 99% percent of larger firms offer spousal health benefits.

Data Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2016.

Source: Kaiser Family Foundation: Access to Employer-Sponsored Health Coverage for Same-Sex Spouses

Cigarette Smoking among Current Adult E-Cigarette Users

Notes: Adults were asked if they had smoked at least 100 cigarettes in their lifetime and, if yes, whether they currently smoked cigarettes every day, some days, or not at all. Those who smoked every day or some days were classified as current cigarette smokers. Adults who had not smoked 100 cigarettes were classified as never cigarette smokers. Adults who had smoked 100 cigarettes but were not smoking at the time of interview were classified as former cigarette smokers. Percentages are shown with 95% confidence intervals.
Current e-cigarette use was based on responses of “every day” or “some days” to the question, “Do you currently use electronic cigarettes every day, some days, or not at all?” asked of adults who had ever tried an e-cigarette, even one time.
Estimates are based on household interviews of a sample of the noninstitutionalized U.S. civilian population aged ≥18 years and are derived from the National Health Interview Survey sample adult component.

Data Source: National Health Interview Survey, 2015 data.

Source: Centers for Disease Control and Prevention: Cigarette Smoking Status Among Current Adult E-cigarette Users, by Age Group — National Health Interview Survey, United States, 2015

Insurer Participation in the 2017 Individual Marketplace by County

 

Notes: We define the number of insurers in a single county as the number of insurers (grouped by parent company or group affiliation) that offer at least one silver plan in the county. For states that do not use healthcare.gov in 2017, insurer participation is estimated based on information gathered from state exchange websites, insurer press releases, and media reports as of August 26, 2016. States that do not use healthcare.gov in 2017 are: California, Colorado, Connecticut, District of Columbia, Idaho, Maryland, Massachusetts, Minnesota, New York, Rhode Island, Vermont, and Washington. See the interactive map here: https://public.tableau.com/profile/kaiser.family.foundation#!/vizhome/InsurerParticipationinthe2017IndividualMarketplace/2017InsurerParticipation

Data Source: Kaiser Family Foundation analysis of data from the 2017 QHP Landscape file released by healthcare.gov on October 24, 2016.

Source: Kaiser Family Foundation: Insurer Participation in the 2017 Individual Marketplace

Number of Reported Hacking and IT Breaches Affecting Health Care Records of 500 People or More

Note: In January 2015, the Office of Civil Rights (OCR) provided additional guidance to reporting entities which directed them to report some breaches as hacking or IT incidents instead of as theft as they may have previously reported.

Data Source: GAO analysis of Department of Health and Human Services data.

Source: U.S. Government Accountability Office: Electronic Health Information: HHS Needs to Strengthen Security and Privacy Guidance and Oversight

Medicaid Enrollment and Total Spending Growth

Notes: Percentages reflect the median percent change for each group of states for each year. FY 2017 growth reflects projections in enacted budgets. In FY 2016, Alaska and Montana moved and in FY 2017, Louisiana moved to the expansion state group.

Data Source: Enrollment growth for FY 2015-2016 is based on KCMU analysis of CMS, Medicaid & CHIP Monthly Applications, Eligibility Determinations, and Enrollment Reports, accessed October 2016. The spending growth rate for FY 2015 is derived from KCMU Analysis of CMS Form 64 Data. All other growth rates are from the KCMU survey of Medicaid officials in 50 states and DC conducted by Health Management Associates, October 2016.

Source: Kaiser Family Foundation: Medicaid Enrollment & Spending Growth: FY 2016 & 2017

Percentage of Young Children with Elevated Blood Lead Levels

Notes: 95% confidence intervals are represented by error bars.
Among children 1 to 5 years of age.
CDC currently uses ≥5 µg/dL as a reference level to identify children with elevated blood lead levels.
Totals include data for racial/ethnic groups not shown separately.

Data Source: The National Health and Nutrition Examination Survey.

Source: Centers for Disease Control and Prevention: Percentage of Children Aged 1–5 Years with Elevated Blood Lead Levels, by Race/Ethnicity — National Health and Nutrition Examination Survey, United States, 1988–1994, 1999–2006, and 2007–2014

Mental Health Care Received among Adults with Serious Mental Illness

Notes: + Difference between this estimate and the 2015 estimate is statistically significant at the 0.05 level.
Among adults aged 18 or older with serious mental illness in the past year.

Source: Substance Abuse and Mental Health Services Administration: Key Substance Use and Mental Health Indicators in the United States: Results from the 2015 National Survey on Drug Use and Health

Rate of Vaginal Deliveries and Cesarean Sections

Notes: Data are from 43 states and the District of Columbia. C-section is cesarean section.

Data Source: Agency for Healthcare Research and Quality (AHRQ), Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project (HCUP), State Inpatient Databases (SID), 43 States and the District of Columbia, 2013.

Source: Agency for Healthcare Research and Quality/Healthcare Cost and Utilization Project: Variation in the Rate of Cesarean Section Across U.S. Hospitals, 2013

Uninsured Rate by Age

Notes: Among the civilian noninstitutionalized population. For information on confidentiality protection, sampling error, nonsampling error, and definitions in the American Community Survey, see www2.census.gov/programs-surveys/acs/tech_docs/accuracy/ACS_Accuracy_of_Data_2015.pdf.

Data Source: U.S. Census Bureau, 2013, 2014, and 2015 1-Year American Community Surveys.

Source: U.S. Census Bureau: Health Insurance Coverage in the United States: 2015

Medicare Part D Total Spending per EpiPen Prescription

Notes: Analysis includes Medicare beneficiaries who had at least one month of Part D coverage and at least one prescription drug event for the EpiPen during the year. Spending estimates do not take into account rebates and are not inflation-adjusted.

Data Source: Kaiser Family Foundation analysis of a five percent sample of Medicare prescription drug event claims, 2007-2014.

Source: Kaiser Family Foundation: How Much Has Medicare Spent on the EpiPen Since 2007?

COPD-Related Death Rates

Notes: 1 Statistically significant increase in COPD-related death rate between 2000 and 2014 (p < 0.05).
2 Statistically significant decrease in COPD-related death rate between 2000 and 2014 (p < 0.05).
COPD is chronic obstructive pulmonary disease. COPD-related deaths were identified as those with COPD (ICD–10 code J40–J44) reported anywhere on the death certificate (i.e., as an underlying or a contributing cause of death).

Data Source: NCHS, National Vital Statistics System mortality data, 2000 and 2014.

Source: Centers for Disease Control and Prevention/National Center for Health Statistics: COPD-related Mortality by Sex and Race Among Adults Aged 25 and Over: United States, 2000–2014

Death Rates for the Top Five Causes of Cancer Death

Notes: Death rates are age-adjusted.
Deaths per 100,000 standard population. Breast cancer death rate is per 100,000 females; prostate cancer is per 100,000 males. These breast and prostate cancer death rates differ from those published by National Center for Health Statistics, which are based on the population of both sexes. The top five cancer causes overall were also the top five for the non-Hispanic white and black populations, but prostate cancer was not among the top five for the Hispanic population.
As the underlying causes of death, lung and bronchus cancer was coded as C34, colorectal cancer as C18–C20, breast cancer as C50, pancreatic cancer as C25, and prostate cancer as C61 based on the International Classification of Diseases, 10th revision.

Data Source: National Vital Statistics System. Underlying cause of death data, 2014.

Source: Centers for Disease Control and Prevention: Age-Adjusted Death Rates for Top Five Causes of Cancer Death, by Race/Hispanic Ethnicity — United States, 2014

Established Drugs under Medicare Part D That Experienced an Extraordinary Price Increase

Note: A price increase of at least 100 percent from the first quarter of one year to the first quarter of the next is considered an extraordinary price increase. To be considered an established drug, a drug had to be in the Medicare Part D claims data for each quarter from the first quarter of 2009 through the second quarter of 2015 and meet certain other data reliability standards. A total of 1,441 drugs met these criteria.

Data Source: GAO analysis of Medicare Part D prescription drug event data.

Source: U.S. Government Accountability Office: Generic Drugs Under Medicare: Part D Generic Drug Prices Declined Overall, but Some Had Extraordinary Price Increases

Prevalence of Food Insecurity in U.S. Households

Note: Prevalence rates for 1996 and 1997 were adjusted for the estimated effects of differences in data collection screening protocols used in those years.

Data Source: USDA, Economic Research Service using data from U.S. Department of Commerce, U.S. Census Bureau, Current Population Survey Food Security Supplement.

Source: U.S. Department of Agriculture/Economic Research Service: Household Food Security in the United States in 2015

Medicare per Capita Spending by Type of Service

Notes: Analysis excludes beneficiaries in Medicare Advantage. SNF is skilled nursing facility. 65-year olds are excluded because they are enrolled for less than a full year.

Data Source: Kaiser Family Foundation analysis of a five percent sample of Medicare claims from the CMS Chronic Condition Data Warehouse, 2014.

Source: Kaiser Family Foundation: Similar but Not the Same: How Medicare Per Capita Spending Compares for Younger and Older Beneficiaries

Birth Rates among Teens

Notes: For American Indian or Alaska Natives and Asian or Pacific Islanders, includes persons of Hispanic and non-Hispanic ethnicity. Data are for U.S. residents only. Data for 2015 are preliminary.

Data Source: Hamilton BE, Martin JA, Osterman MJK. Births: preliminary data for 2015. National Vital Statistics Reports, Vol. 65, No. 3. Hyattsville, MD: National Center for Health Statistics; 2016.

Source: Centers for Disease Control and Prevention: Birth Rates Among Teens Aged 15–19 Years, by Race/Hispanic Ethnicity — National Vital Statistics System, United States, 2007 and 2015

Uninsured Adults by Income Level

Notes: FPL refers to federal poverty level. 138% of the poverty level is $16,243 for an individual or $33,465 for a family of four. 250% of the poverty level is $29,425 for an individual or $60,625 for a family of four.

Data Source: The Commonwealth Fund Affordable Care Act Tracking Surveys, July–Sept. 2013 and February–April 2016.

Source: The Commonwealth Fund: Who Are the Remaining Uninsured and Why Haven’t They Signed Up for Coverage?

Medicaid Spending on Long Term Services and Supports by State

Notes: Per full-benefit enrollee. MLTSS programs for seniors were in place in AZ, HI, MN, TN, VT, and WI. Because of the way the MLTSS data are categorized, we were unable to calculate reliable spending per enrollee estimates for these states. We were also unable to report spending for New Mexico, due to a spending data reliability issue for senior enrollees in the New Mexico CoLTS program. These states were withheld from the national spending per full-benefit senior enrollee calculation.

Data Source: KCMU and Urban Institute estimataes based on data from FY 2011 MSIS and CMS-64 reports. Because 2011 data were unavailable, 2010 data was used for FL, KS, ME, MD, MT, NM, NJ, OK, TX, and UT.

Source: Kaiser Family Foundation: Medicaid’s Role in Meeting Seniors’ Long-Term Services and Supports Needs

Medicare Expenditures and Administrations of Part B Drugs

Note: In 2014, Medicare spent about $21 billion on approximately 46 million administrations of Part B drugs paid based on average sales price (ASP). We defined expenditures as the total amount spent by the Medicare fee-for-service program and its beneficiaries, and administrations as the number of claim line items for a drug. Both measures included only those for claim line items that Medicare paid based on ASP. The figure includes all provider specialties that accounted for at least 3 percent of expenditures or administrations on Part B ASP drugs.

Data Source: GAO analysis of Centers for Medicare & Medicaid Services data.

Source: Government Accountability Office: Medicare Part B: CMS Should Take Additional Steps to Verify Accuracy of Data Used to Set Payment Rates for Drugs

Sports-Related Emergency Department Visits and Hospital Inpatient Stays

Notes: For fewer than 1% of ED visits and inpatient stays, more than one sports activity was identified. In these cases, the visit or stay is counted separately for each identified sports activity. The “other specified sports and athletics” category includes boxing, wrestling, and martial arts. The “other muscle strengthening exercises” category includes exercise machines, free weights, and Pilates. The “other cardiorespiratory exercise” category includes calisthenics, aerobics, and circuit training.

Data Source: Agency for Healthcare Research and Quality (AHRQ), Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project (HCUP), National Inpatient Sample (NIS) and Nationwide Emergency Department Sample (NEDS), 2013.

Source: Agency for Healthcare Research and Quality/Healthcare Cost and Utilization Project: Sports-Related Emergency Department Visits and Hospital Inpatient Stays, 2013

Reasons Why Consumers Say They Changed Health Plans

Notes: Adults ages 19–64 who changed marketplace plans.
Forty-six percent of adults ages 19–64 who have had marketplace coverage since before January 2016 switched plans since enrolling.

Data Source: The Commonwealth Fund Affordable Care Act Tracking Survey, February–April 2016.

Source: The Commonwealth Fund: Americans’ Experiences with ACA Marketplace Coverage: Affordability and Provider Network Satisfaction

Expected Source of Payment for Emergency Department Visits

Notes: Emergency department visits made by adults aged 18–64: United States, 2012.
1 Significantly different from private (p < 0.05).
2 Significantly different from Medicaid and no insurance (p < 0.05).
Among adults aged 18–64, there were 27,500,000 emergency department visits with private insurance as the expected source of payment,17,608,000 with Medicaid, 16,728,000 with no insurance, 8,970,000 with unknown or blank, 7,482,000 with Medicare, and 4,141,000 with workers’ compensation or other types of insurance. No insurance is defined as having only self-pay, no charge, charity, or a combination of these types as payment sources.

Data Source: NCHS, National Hospital Ambulatory Medical Care Survey, 2012.

Source: Centers for Disease Control and Prevention/National Center for Health Statistics: Expected Source of Payment at Emergency Department Visits for Adults Aged 18–64 for the United States and in the Five Most Populous States, 2012

ACA Coverage Eligibility Among Low-Income Workers

Notes: In 2015. Medicaid expansion states include the 32 states (including DC) that have adopted the Medicaid expansion as of April 2016. Wisconsin covers adults up to 100% FPL in Medicaid but did not adopt the Medicaid Expansion. Tax Credit Eligible includes adults in MN and NY who are eligible for coverage through the Basic Health Plan. Low-income workers are nonelderly adult workers ages 19-64 with household incomes <250% FPL. *Indicates a statistically significant difference from Medicaid expansion states at p<.05 level. Data may not sum to 100% due to rounding.

Data Source: Kaiser Family Foundation analysis based on 2015 Medicaid eligibility levels updated to reflect state Medicaid expansion decisions as of April 2016 and 2015 ASEC Supplement to the CPS.

Source: Kaiser Family Foundation: ACA Coverage Expansions and Low-Income Workers

Women’s Contraceptive Choices are Changing

Note: More than one method may be used by a woman, but these data only reflect most effective method used.

Data Source: Daniels K, Daugherty J, Jones J, & Mosher W. Current Contraceptive Use and Variation by Selected Characteristics Among Women Aged 15-44: United States, 2011-2013. National Health Statistics Reports; no. 86. November 10, 2015.

Source: Kaiser Family Foundation: Oral Contraceptive Pills

Percent of Uninsured Adults, by Sex and State’s Medicaid-Expansion Status

Note: Non-elderly adults aged 18 to 64 who were uninsured for the entire year, 2013 and 2014.

Data Source: Medical Expenditure Panel Survey — Household Component, 2013-2014.

Source: Agency for Healthcare Research and Quality/Medical Expenditure Panel Survey: The Uninsured in America: Estimates of the Percentage of Non- Elderly Adults Uninsured throughout Each Calendar Year, by Selected Population Subgroups and State Medicaid Expansion Status: 2013 and 2014

Prevalence of Adults with Hypertension Who Are Aware They Have Hypertension

Notes: 95% confidence intervals indicated by error bars.
Age-adjusted, using the subpopulation of persons aged ≥18 years with hypertension during 2011–2014.
Respondents were defined as having hypertension if their systolic blood pressure was ≥140 mm Hg or their diastolic blood pressure was ≥90 mm Hg, or they were currently taking medication to lower high blood pressure.
Respondents with hypertension who answered “yes” to the question, “Have you ever been told by a doctor or health professional that you had hypertension, also called high blood pressure?”

Data Sources: Nwankwo T, Yoon SS, Burt V, Gu Q. Hypertension among adults in the United States: National Health and Nutrition Examination Survey, 2011–2012. NCHS data brief no. 133; 2013; CDC. National Health and Nutrition Examination Survey data. Hyattsville, MD: US Department of Health and Human Services, CDC, National Center for Health Statistics; 2013–2014.

Source: Centers for Disease Control and Prevention: Age-Adjusted Prevalence of Adults Aged ≥18 Years with Hypertension Who Are Aware They Have Hypertension, by Sex and Race/Ethnicity — National Health and Nutrition Examination Survey, United States, 2011–2014

Rate of Discharge to Postacute Care by Payer

Notes: During the year 2013.
PAC stands for postacute care.
Discharges to inpatient rehabilitation facilities and long-term care hospitals were not identified in one State in the Pacific area. As a result, the rate of discharge to PAC in the Pacific area may be underestimated.

Data Source: Agency for Healthcare Research and Quality (AHRQ), Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project (HCUP), National Inpatient Sample (NIS), 2013.

Source: Agency for Healthcare Research and Quality/Healthcare Cost and Utilization Project: An All-Payer View of Hospital Discharge to Postacute Care, 2013

Adults Who Reported Poor Communication with Health Providers

Notes: Among adults who had a doctor’s office or clinic visit in the past 12 months.
Adults who reported that their health providers sometimes or never listened carefully, explained things clearly, showed respect for what they had to say, or spent enough time with them are considered to have poor communication.

Data Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2013.

Source: Agency for Healthcare Research and Quality: 2015 National Healthcare Quality and Disparities Report and 5th Anniversary Update on the National Quality Strategy

Adults Who Met Federal Guidelines for Aerobic Physical Activity

Notes: Error bars indicate 95% confidence intervals.
Per U.S. Department of Health and Human Services 2008 Physical Activity Guidelines for Americans. Respondents were considered to be meeting aerobic activity guidelines if they reported moderate-intensity physical activity for ≥150 minutes leisure-time activity per week, vigorous-intensity physical activity for ≥75 minutes leisure-time activity per week, or an equivalent combination of moderate-intensity and vigorous-intensity leisure-time activity.
Poverty status is based on family income and family size using the 2013 U.S. Census Bureau poverty thresholds. Family income was imputed where missing.
Estimates are based on household interviews of a sample of the civilian, noninstitutionalized U.S. population and are derived from the National Health Interview Survey sample adult component.

Data Source: National Health Interview Survey data, 2014.

Source: Centers for Disease Control and Prevention: Percentage of Adults Who Met Federal Guidelines for Aerobic Physical Activity, by Poverty Status — National Health Interview Survey, United States, 2014

Total Medicare Private Health Plan Enrollment

Note: Includes cost and demonstration plans, and enrollees in Special Needs Plans as well as other Medicare Advantage plans.

Data Sources: Congressional Budget Office’s March 2016 Medicare Baseline, CMS Medicare Advantage enrollment files for 2008-2014, and MPR’s “Tracking Medicare Health and Prescription Drug Plans Monthly Report” for 1992-2007.

Source: Kaiser Family Foundation: Total Medicare Private Health Plan Enrollment, Current and Projected

Adults with a Recent Visit to a Health Professional Who Received Dietary Advice

Notes: Among adults with a visit to a health professional in the past 12 months.
Error bars represent 95% confidence intervals.
Based on the question, “During the last 12 months, has a doctor or other health professional talked to you about your diet?”
Obesity status was based on respondent-reported height and weight and calculated as body mass index (BMI) using the following formula: BMI = weight/height2 (kg/m2). An adult who was obese had a BMI ≥30; an adult who was not obese had a BMI <30.
Estimates are based on household interviews of a sample of the noninstitutionalized U.S. civilian population and were derived from the National Health Interview Survey Sample Adult component.

Data Source: National Health Interview Survey, 2014 data.

Source: Centers for Disease Control and Prevention: Percentage of Adults with a Visit to a Health Professional in the Past 12 Months Who Received Dietary Advice, by Obesity Status and Age Group — National Health Interview Survey, United States, 2014

High-School Students Who Currently Use Tobacco Products

Notes: Any tobacco product use is defined as past 30-day use of cigarettes, cigars, smokeless tobacco, electronic cigarettes (e-cigarettes), hookahs, pipe tobacco, and/or bidis.
≥2 tobacco product use is defined as past 30-day use of two or more of the following product types: cigarettes, cigars, smokeless tobacco, e-cigarettes, hookahs, pipe tobacco, and/or bidis.
E-cigarettes and hookahs demonstrated a nonlinear increase (p < 0.05). Cigarettes and smokeless tobacco demonstrated a linear decrease (p < 0.05). Cigars, pipe tobacco, and bidis demonstrated a nonlinear decrease (p < 0.05).

Source: Centers for Disease Control and Prevention: Tobacco Use Among Middle and High School Students — United States, 2011–2015

Distribution of Deaths, by Place of Death

Notes: Percentage was calculated as (deaths occurred in a place/all deaths) x 100.
Excludes all deaths from external causes defined by International Classification of Diseases, Tenth Revision (ICD-10) codes V01-Y89 and cause-of-death codes U01–U03.
Deaths in hospice and all other places include those in a hospice facility; all other places other than hospital, nursing home, and home; and unknown place of death. The category “hospice” was introduced with the revised death certificate in 2003. The number of states using the revised death certificate grew from four states in 2003 to 46 states and the District of Columbia in 2014.

Data Source: National Vital Statistics System. Underlying cause of death data, 2000–2014.

Source: Centers for Disease Control and Prevention: Percentage Distribution of Deaths, by Place of Death — United States, 2000–2014

Hospital Stays Including Mental-Disorder Diagnoses among Teenagers

Notes: Data are on the top three mental-disorder diagnoses and are from 2012. Mental-disorder diagnoses are based on any principal or secondary (all-listed) diagnosis or external cause of injury or poisoning. Teenagers are defined as ages 13 to 19 (inclusive).

Data Source: Agency for Healthcare Research and Quality (AHRQ), Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project (HCUP), Kids’ Inpatient Database (KID), 2012.

Source: Agency for Healthcare Research and Quality/Healthcare Cost and Utilization Project: Mental and Substance Use Disorders Among Hospitalized Teenagers, 2012

Current Asthma Prevalence among Adults

Notes: 1 Significantly higher than normal weight (p < 0.05).
2 Significantly higher than overweight (p < 0.05).
Among adults 20 years of age and over. Age adjusted by the direct method to the 2000 U.S. Census population using age groups 20–39, 40–59, and 60 and over.

Data Source: CDC/NCHS, National Health and Nutrition Examination Survey, 2011–2014.

Source: Centers for Disease Control and Prevention/National Center for Health Statistics: Current Asthma Prevalence by Weight Status Among Adults: United States, 2001–2014

SNAP Eligibility and Participation

Notes: SNAP stands for Supplemental Nutrition Assistance Program.
This figure uses annual Agriculture Department (USDA) estimates of eligible and participating individuals. USDA revised the methodology for these estimates starting with the 2010 estimates, so the 2007, 2009 and 2013 estimates are not directly comparable. The revised methodology does not change the underlying trends.

Data Source: USDA Food and Nutrition Service, “Supplemental Nutrition Assistance Program Participation Rates: Fiscal Year 2010 to 2013” August 2015, and earlier reports in the series.

Source: Center on Budget and Policy Priorities: SNAP Costs and Caseloads Declining

Measures of Medicare Beneficiaries’ Health Status, by Race/Ethnicity

Notes: Data are from 2011.
* Denotes statistically significant difference at the 95% confidence level from whites. Functional impairment is defined as one or more limitations in activities of daily living (eating, dressing, getting into/out of bed/chair, bathing/showering, using the toilet, difficulty walking). Cognitive/mental impairment is defined as presence of memory loss that interferes with daily activity, difficulty making decisions, trouble concentrating, and loss of interest within the past year. For facility residents, definition includes ability to recall names and faces, current season, location of nursing home and room.

Data Source: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey Cost and Use File, 2011.

Source: Kaiser Family Foundation: Profile of Medicare Beneficiaries by Race and Ethnicity: A Chartpack

Medicaid Income Eligibility Limits in States That Have Not Expanded Medicaid

Notes: As of January 2016.
Eligibility levels are based on 2016 federal poverty levels (FPLs) and are calculated based on a family of three for parents and an individual for childless adults. In 2016, the FPL was $20,160 for a family of three and $11,880 for an individual. Thresholds include the standard five percentage point of the federal poverty level (FPL) disregard.
* Louisiana has adopted the Medicaid expansion, but it has not yet been implemented.

Data Source: Based on results from a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2016.

Source: Kaiser Family Foundation: Where Are States Today? Medicaid and CHIP Eligibility Levels for Adults, Children, and Pregnant Women

Physician Office Visits with Selected Chronic Conditions, by Visit Diagnosis

Notes: 1 Difference between visits for obesity and visits for all other diagnoses is statistically significant (p < 0.05).
A visit for obesity is a visit in which obesity is listed by the provider as one of up to three diagnoses for the visit.

Data Source: CDC/NCHS, National Ambulatory Medical Care Survey, 2012.

Source: Centers for Disease Control and Prevention/National Center for Health Statistics: Characteristics of Physician Office Visits for Obesity by Adults Aged 20 and Over: United States, 2012

Percent Distribution of Long-Term Care Services Users, by Age

Notes: Denominators used to calculate percentages for adult day services centers, nursing homes, and residential care communities were the number of current participants enrolled in adult day services centers, the number of current residents in nursing homes, and the number of current residents in residential care communities in 2014, respectively. Denominators used to calculate percentages for home health agencies and hospices were the number of patients who received care from Medicare-certified home health agencies at any time in 2013 and the number of patients who received care from Medicare-certified hospices at any time in 2013, respectively. See Technical Notes for more information on the data sources used for each sector. Percentages may not add to 100 because of rounding. Percentages are based on the unrounded numbers.

Data Source: CDC/NCHS, National Study of Long-Term Care Providers and Table 4 in Appendix B.

Source: Centers for Disease Control and Prevention/National Center for Health Statistics: Long-Term Care Providers and Services Users in the United States: Data From the National Study of Long-Term Care Providers, 2013–2014

Adults with Two or More Visits to the ED in the Past Year

Notes: Among adults 18–64 years of age.
Error bars represent 95% confidence intervals.
Based on a response to the survey question “During the past 12 months, how many times have you gone to a hospital emergency room about your own health? (This includes emergency room visits that resulted in a hospital admission.)”
Health insurance coverage is based on the status at the time of interview. Private includes plans obtained through an employer, purchased directly, through local or community programs, through the Health Insurance Marketplace, or a state-based exchange. Medicaid includes those without private insurance who reported Medicaid, Children’s Health Insurance Program, or other state-sponsored health plans. Uninsured includes those without any private health insurance, Medicaid, Medicare, other government-sponsored health plan, military plan, or Indian Health Service coverage only, or those who had a private plan that paid for one type of service.
Persons of Hispanic ethnicity may be of any race or combination of races.
Estimates are based on household interviews of a sample of the civilian noninstitutionalized U.S. population and are derived from the National Health Interview Survey family core and sample adult components.

Data Source: Gindi RM, Black LI, Cohen RA. Reasons for emergency room use among US adults aged 18–64: National Health Interview Survey, 2013 and 2014. National Health Statistics Reports, No. 90. Hyattsville, MD: National Center for Health Statistics; 2016. http://www.cdc.gov/nchs/data/nhsr/nhsr090.pdf.

Source: Centers for Disease Control and Prevention: Percentage of Adults Aged 18–64 Years with Two or More Visits to the Emergency Department in the Past 12 Months, by Health Insurance Coverage Status, and Race/Ethnicity — National Health Interview Survey, 2014

Uses of Premium Revenues in Fully Insured Markets, 2010 to 2012

Notes: The small-group market generally serves employers with up to 50 employees.
A fully insured plan is one in which the insurer bears the risk; that is, the insurer incurs the added costs if expenditures are higher than expected and keeps the savings if expenditures are lower than expected.

Data Source: Congressional Budget Office, using 2010 filings of the Supplemental Health Care Exhibit (National Association of Insurance Commissioners) and 2011 and 2012 filings of the Medical Loss Ratio Annual Reporting Form (Centers for Medicare & Medicaid Services).

Source: Congressional Budget Office: Private Health Insurance Premiums and Federal Policy

Prevalence of Maternal Smoking before and during Pregnancy

Notes: Data are from 46 states and District of Columbia in 2014.
Smoking before pregnancy is defined as smoking in the 3 months before pregnancy.

Data Source: CDC/NCHS, National Vital Statistics System.

Source: Centers for Disease Control and Prevention/National Center for Health Statistics: Smoking Prevalence and Cessation Before and During Pregnancy: Data From the Birth Certificate, 2014

Years of Life Lost to Disability and Premature Death Due to Firearm Assaults

Data Source: Kaiser Family Foundation analysis of data from the University of Washington Institute for Health Metrics and Evaluation. Available at: http://ghdx.healthdata.org/global-burden-disease-study-2013-gbd-2013-data-downloads (Accessed on November 23, 2015).

Source: Peterson-Kaiser Health System Tracker: What do we know about social determinants of health in the U.S. and comparable countries?

Percentage of Firms Offering Health Benefits

Notes: * Estimate is statistically different from estimate for the previous year shown (p < 0.05).
Estimates presented in this exhibit are based on the sample of both firms that completed the entire survey and those that answered just one question about whether they offer health benefits.

Data Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2000-2015.

Source: Kaiser Family Foundation: A Comparison of the Availability and Cost of Coverage for Workers in Small Firms and Large Firms: Update from the 2015 Employer Health Benefits Survey

Cancer Mortality in the U.S. and Comparable Countries

Notes: Comparable countries are defined as those with above median GDP and above median GDP per capita in at least one of the past ten years. Break in series in 1987 and 1997 for Switzerland; in 1995 for Switzerland; in 1996 for Netherlands; in 1998 for Australia, Belgium, and Germany; in 1999 for United States; in 2000 for Canada and France; and in 2001 in the United Kingdom. All breaks in series coincide with changes in ICD coding.

Data Source: Kaiser Family Foundation analysis of 2013 OECD data: “OECD Health Data: Health status: Health status indicators”, OECD Health Statistics (database). doi: 10.1787/data-00540-en (Accessed on January 22, 2016).

Source: Peterson-Kaiser Health System Tracker: What are recent trends in cancer spending and outcomes?

Rate of Preventive Care Visits, by Sex and Age in 2012

Notes: 1 Difference between rates for under age 18 years and age groups 18–44 and 45–64 is statistically significant (p < 0.05).
2 Difference between rates for 65 and over and age groups 18–44 and 45–64 is statistically significant (p < 0.05).
3 Difference between women aged 45–64 and all other age groups is statistically significant (p < 0.05).
4 Difference by gender is statistically significant (p < 0.05).
5 Difference between men aged 18–44 and 45–64 is statistically significant (p < 0.05).

Data Source: CDC/NCHS, National Ambulatory Medical Care Survey, 2012.

Source: Centers for Disease Control and Prevention/National Center for Health Statistics: State Variation in Preventive Care Visits, by Patient Characteristics, 2012

Rate of Drug Overdose Deaths

Notes: Age-adjusted death rates were calculated by applying age-specific death rates to the 2000 U.S. standard population age distribution.
Drug overdose deaths are identified using International Classification of Diseases, Tenth Revision underlying cause-of-death codes X40–X44, X60–X64, X85, and Y10–Y14.
Drug overdose deaths involving opioids are drug overdose deaths with a multiple cause-of-death code of T40.0, T40.1, T40.2, T40.3, T40.4, or T40.6. Approximately one fifth of drug overdose deaths lack information on the specific drugs involved. Some of these deaths might involve opioids.
Opioids include drugs such as morphine, oxycodone, hydrocodone, heroin, methadone, fentanyl, and tramadol.

Data Source: National Vital Statistics System, Mortality file.

Source: Centers for Disease Control and Prevention: Increases in Drug and Opioid Overdose Deaths — United States, 2000–2014

Requests the FDA Granted and Denied for Fast-Track Designation

Note: In addition to requests granted and denied during the period, 33 requests for fast track designation were withdrawn by the sponsor and 7 were classified by FDA as other. According to FDA, the category of other includes cases where the drug application was inactivated, terminated, or cancelled before FDA made a decision (grant or deny) or if the request is still pending.

Data Source: GAO analysis of FDA data.

Source: U.S. Government Accountability Office: Drug Safety: FDA Expedites Many Applications, But Data for Postapproval Oversight Need Improvement

Older Adults with Chronic Conditions, by Country

Notes: * Reported having hypertension or high blood pressure, heart disease, diabetes, lung problems, mental health problems, cancer, and/or joint pain/arthritis.
Among adults 65 years of age and older.

Data Source: 2014 Commonwealth Fund International Health Policy Survey of Older Adults.

Source: The Commonwealth Fund: How High-Need Patients Experience the Health Care System in Nine Countries

Percentage of Adults Who Get Less Than 7 Hours of Sleep Daily

Notes: 1 Significantly different from single parents.
2 Significantly different from adult in two-parent family.
3 Significantly different from women within the same family type.
Among adults 18 to 64 years of age. Single parent includes legal guardians. Both single-parent and two-parent families are limited to those in which no other adults are living in the household.

Data Source: CDC/NCHS, National Health Interview Survey, 2013–2014.

Source: Centers for Disease Control and Prevention/National Center for Health Statistics: Sleep Duration, Quality of Sleep, and Use of Sleep Medication, by Sex and Family Type, 2013–2014

Rate of Heart Failure-Related Deaths

Notes: Rates are age-adjusted. Heart failure-related deaths are those with heart failure (ICD–10 code I50) reported anywhere on the death certificate (i.e., as an underlying or contributing cause of death).
1 Age-adjusted rate of heart failure-related deaths declined significantly from 2000 through 2012 and then increased from 2012 through 2014 for the overall population and for the non-Hispanic white and non-Hispanic black populations (p < 0.05).
2 Age-adjusted death rate was significantly higher for the non-Hispanic black population than for the non-Hispanic white and Hispanic populations (p < 0.05).
3 Declining trend in the age-adjusted rate of heart failure-related deaths for the Hispanic population from 2000 through 2014 was statistically significant (p < 0.05).

Data Source: CDC/NCHS, National Vital Statistics System mortality data, 2000–2014.

Source: Centers for Disease Control and Prevention/National Center for Health Statistics: Recent Trends in Heart Failure-related Mortality: United States, 2000–2014

Adults Who Looked Up Health Information on the Internet in the Past Year

Notes: Error bars represent 95% confidence intervals.
Based on sample adult’s response to a question asking if, during the past 12 months, the person ever used computers to look up health information on the Internet. Responses were not limited to those who indicated that they had Internet access.
Counties were classified into urbanization levels based on a classification scheme developed by the National Center for Health Statistics, CDC, that considers metropolitan/nonmetropolitan status, population, and other factors.
Estimates are based on household interviews of a sample of the civilian, noninstitutionalized U.S. population and are derived from the National Health Interview Survey sample adult questionnaire.

Data Sources: National Health Interview Survey. Available at http://www.cdc.gov/nchs/nhis.htm. Ingram DD, Franco SJ. NCHS urban-rural classification scheme for counties. National Center for Health Statistics. Vital Health Stat 2012;2(154).

Source: Centers for Disease Control and Prevention: Percentage of U.S. Adults Who Looked up Health Information on the Internet in the Past Year, by Type of Locality — National Health Interview Survey, 2012–2014

Rate of Hospital Readmissions by Expected Payer

Notes: The expected payer is determined by the index admission, not the readmission. Rates by expected payer include all patients aged 1 year and older.

Data Sources: Agency for Healthcare Research and Quality (AHRQ), Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project (HCUP), 2013 Nationwide Readmissions Database (NRD), and readmissions analysis files derived from the 2009–2012 State Inpatient Databases (SID).

Source: Agency for Healthcare Research and Quality/Healthcare Cost and Utilization Project: All-Cause Readmissions by Payer and Age, 2009–2013

Death Rates for the 10 Leading Causes of Death

Notes: Death rates are age-adjusted. A total of 2,626,418 resident deaths were registered in the United States in 2014. The 10 leading causes accounted for 73.8% of all deaths in the United States in 2014. Causes of death are ranked according to number of deaths.

Data Source: CDC/NCHS, National Vital Statistics System, Mortality.

Source: Centers for Disease Control and Prevention/National Center for Health Statistics: Mortality in the United States, 2014

Persons Who Were in Families Having Problems Paying Medical Bills

Notes: Among persons under age 65. Problems paying medical bills refers to the past 12 months.
Data are based on household interviews of a sample of the civilian noninstitutionalized population.
1 Significant linear decrease from 2011 through June 2015 (p < 0.05).
2 Hispanic persons were significantly different from Non-Hispanic white, Non-Hispanic black, and Non-Hispanic Asian persons within each year (p < 0.05).
3 Non-Hispanic white persons were significantly different from Non-Hispanic black and Non-Hispanic Asian persons within each year (p < 0.05).
4 Non-Hispanic black persons were significantly different from Non-Hispanic Asian persons within each year (p < 0.05).

Data Sources: CDC/NCHS, National Health Interview Survey, 2011–2015.

Source: Centers for Disease Control and Prevention/National Center for Health Statistics: Problems Paying Medical Bills Among Persons Under Age 65: Early Release of Estimates From the National Health Interview Survey, 2011–June 2015

Percentage of Uninsured Persons with No Health Insurance Because of Cost

Notes: Among persons less than 65 years of age.
Error bars represent 95% confidence intervals.
Based on the family respondent’s response to a survey question that asked about uninsured family members, “Which of these are reasons (person) stopped being covered or does not have health insurance?” Reasons included lost job or change in employment, change in marital status or death of a parent, ineligible because of age or left school, employer didn’t offer or insurance company refused, cost, Medicaid stopped, and other reason. More than one reason could be provided.
Persons of Hispanic ethnicity might be of any race or combination of races.
Estimates are based on household interviews of a sample of the civilian, noninstitutionalized U.S. population and are derived from the National Health Interview Survey Family core component. Unknowns were excluded from the denominators when calculating percentages.

Data Sources: Adams PF, Barnes PM. Summary Health Statistics for the U.S. Population: National Health Interview Survey, 2004. Vital Health Stat 10(229) 2006. Available at http://www.cdc.gov/nchs/data/series/sr_10/sr10_229.pdf. National Health Interview Survey, 2014 data. Available at http://www.cdc.gov/nchs/nhis.htm.

Source: Centers for Disease Control and Prevention: Percentage of Uninsured Persons Aged <65 Years With No Health Insurance Coverage Because of Cost, by Race/Ethnicity — National Health Interview Survey, United States, 2004 and 2014

Prevalence of High Total Cholesterol among Adults

Notes: 1 Significant difference from non-Hispanic black.
2 Significant difference from men in the same race and Hispanic origin group.
All estimates are age-adjusted by the direct method to the 2000 U.S. census population using three age groups: 20–39, 40–59, and 60 and over.

Data Source: CDC/NCHS, National Health and Nutrition Examination Survey, 2011–2014.

Source: Centers for Disease Control and Prevention/National Center for Health Statistics: Total and High-density Lipoprotein Cholesterol in Adults: United States, 2011–2014

Estimated National Market Shares of the Four Largest Insurers

Notes: This exhibit is constructed using the number of privately insured lives reported in each insurer’s annual reports. Consistency over time and across insurers in terms of products included is not assured. BCBS share (exclusive of Anthem) is estimated using enrollments reported by BCBS for 2010 and 2014, and extrapolating back to 2006 by applying the growth rate in BCBS enrollments from data supplied by the National Association of Insurance Commissioners (NAIC), and corrected for states not reporting or underreporting BCBS enrollment. The BCBS association reports total enrollment of 100 million in 2010 and 106 million in 2014 and may include noncomprehensive insurance. Unfortunately, NAIC reflects only fully insured plans outside of California, whereas this exhibit includes both full and self-insurance for all states. Anthem operates BCBS affiliates in California, Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Michigan, Nevada, New Hampshire, New York, Ohio, Virginia, and Washington. National market size in each year is the number of privately insured lives, as estimated from the Current Population Survey.

Data Source: Current Population Survey, “Total People with Private Health Insurance, 2002–2013,” available at http://www.census.gov/cps/data/cpstablecreator.html.

Source: The Commonwealth Fund: Evaluating the Impact of Health Insurance Industry Consolidation: Learning from Experience

Average Age at Death from HIV Disease

Notes: HIV = human immunodeficiency virus.
The average age at death is the sum of age at death for all HIV deaths, divided by the total number of HIV deaths.
Records with age not stated were not included.
Deaths from HIV disease are identified using underlying causes of death with codes 042-044 (1987–1998) and B20-B24 (1999–2013) in the International Classification of Disease, Ninth and Tenth revisions.

Data Source: National Vital Statistics System. U.S. mortality data files, 1987–2013.

Source: Centers for Disease Control and Prevention: Average Age at Death from HIV Disease, by Sex — United States, 1987–2013

Rate of Hospital Readmission, by Principal Diagnosis of Index Admission

Notes: All-cause readmissions. Principal diagnosis grouped according to the Clinical Classifications Software (CCS).

Data Sources: Agency for Healthcare Research and Quality (AHRQ), Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project (HCUP), 2013 Nationwide Readmissions Database (NRD), and weighted national estimates from readmissions analysis files derived from the 2009-2012 State Inpatient Databases (SID).

Source: Agency for Healthcare Research and Quality/Healthcare Cost and Utilization Project: Trends in Hospital Readmissions for Four High-Volume Conditions, 2009-2013

Persons who Received an Influenza Vaccination during the Past Year

Notes: Data are based on household interviews of a sample of the civilian noninstitutionalized population. Respondents were asked in separate questions if they had received a flu shot during the past 12 months or a flu vaccine sprayed in their nose during the past 12 months. For children 6 months–8 years, who require two doses of vaccine to be fully vaccinated if they have not previously received seasonal influenza vaccination, these questions do not indicate whether the vaccination was a child’s first or second dose. In August 2010, National Health Interview Survey influenza vaccination questions were modified to reflect that, for the first time, the widely available influenza vaccine included protection against both seasonal and H1N1 types of influenza. When interpreting influenza vaccination estimates, changes made to the influenza vaccination questions noted above should be taken into account. Prevalence of influenza vaccination during the past 12 months is different from season-specific coverage (see
http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6204a1.htm?s_cid=ss6204a1_w; estimates available from: http://www.cdc.gov/flu/fluvaxview). Advisory Committee on Immunization Practices recommendations regarding who should receive an influenza vaccination have changed over the years, and changes in coverage estimates may reflect changes in recommendations. The analyses excluded the 2.0% of persons with unknown influenza vaccination status. See Technical Notes for more details.

Data Source: CDC/NCHS, National Health Interview Survey, January–June 2015, combined Sample Adult and Sample Child Core components.

Source: Centers for Disease Control and Prevention/National Center for Health Statistics: Early Release of Selected Estimates Based on Data From the January–June 2015 National Health Interview Survey

Trends in Obesity Prevalence in the United States

Notes: 1 Significant increasing linear trend from 1999–2000 through 2013–2014.
2 Test for linear trend for 2003–2004 through 2013–2014 not significant (p > 0.05).
All adult estimates are age-adjusted by the direct method to the 2000 U.S. census population using the age groups 20–39, 40–59, and 60 and over.

Data Source: CDC/NCHS, National Health and Nutrition Examination Survey.

Source: Centers for Disease Control and Prevention/National Center for Health Statistics: Prevalence of Obesity Among Adults and Youth: United States, 2011–2014

Percentage of Adults who Currently Use Electronic Cigarettes

Notes: * Estimate has a relative standard error greater than 30% but less than 50% and does not meet standards of reliability or precision. The 95% confidence interval is 5.3–20.4.
1 Significantly different from Hispanic, non-Hispanic black, and non-Hispanic Asian subgroups.
AIAN is American Indian or Alaska Native.

Data Source: CDC/NCHS, National Health Interview Survey, 2014.

Source: Centers for Disease Control and Prevention/National Center for Health Statistics: Electronic Cigarette Use Among Adults: United States, 2014

Share of Medicare Beneficiaries Enrolled in Medicare Advantage Plans

Note: Includes MSAs, cost plans, demonstration plans, and Special Needs Plans as well as other Medicare Advantage plans.

Data Source: Kaiser Family Foundation analysis of CMS Medicare Advantage enrollment files, 2008-2015, and MPR, “Tracking Medicare Health and Prescription Drug Plans Monthly Report,” 1999-2007; enrollment numbers from March of the respective year, with the exception of 2006, which is from April.

Source: Kaiser Family Foundation: Medicare Advantage and Traditional Medicare: Is the Balance Tipping?

Monthly Health Spending as a Percentage of Monthly GDP

Notes: Lightly shaded bars denote recession periods.
For further discussion of PGDP, see our blog at http://altarum.org/health-policy-blog/the-case-for-tracking-health-spending-as-a-share-of-potential-gdp

Data Source: Altarum monthly national health spending estimates. Monthly GDP is from Macroeconomic Advisers and Altarum estimates. PGDP is from the U.S. Congressional Budget Office and has been converted to monthly estimates.

Source: Altarum Institute: October 2015 Spending Brief: Latest government data show higher health spending growth, but with recent moderation

Suicide Rates among Young Adults Aged 18-24

Notes: Suicide deaths are identified with ICD–10 codes U03, X60–X84, and Y87.0. Deaths for the American Indian or Alaska Native population may be underreported by 30%, for the Asian or Pacific Islander population by 7%, and for the Hispanic-origin population by 5%. For more details, see Technical Notes in National Vital Statistics Reports, vol. 63, no. 3, “Deaths: Final data for 2011”; also see Vital and Health Statistics, Series 2, no. 148, “The validity of race and Hispanic origin reporting on death certificates in the United States.”

Data Source: CDC/NCHS, National Vital Statistics System mortality data, 2012–2013.

Source: Centers for Disease Control and Prevention/National Center for Health Statistics: Racial and Gender Disparities in Suicide Among Young Adults Aged 18–24: United States, 2009–2013

Medicaid as a Share of Spending by Select Services

Notes: Includes neither spending on CHIP nor administrative spending. Definition of nursing facility care was revised from previous years and no longer includes residential care facilities for mental retardation, mental health or substance abuse. The nursing facility category includes continuing care retirement communities.

Data Source: CMS, Office of the Actuary, National Health Statistics Group, National Health Expenditure Accounts, 2015. Data for 2013.

Source: Kaiser Family Foundation: Medicaid: Moving Forward

Percent Free and Reduced-Price Participation in School Lunch Program

Note: To determine state-level free and reduced-price participation rates, CBO calculated the ratio of 2014 NSLP participants at the free and reduced-price levels to the population ages 5–18.

Data Source: Congressional Budget Office, based on data from the Census Bureau and the Food and Nutrition Service.

Source: Congressional Budget Office: Child Nutrition Programs: Spending and Policy Options

Ambulatory Medical Care Visits Due to Adverse Effects of Care

Notes: Among adults, 2008-2009.

Data Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, 2008-2009.

Source: Agency for Healthcare Research and Quality: 2014 National Healthcare Quality and Disparities Report: Chartbook on Women’s Health Care

Schizophrenia-Related Emergency Department Visits

Notes: Among adults aged 18–64 years.
1 Visit rate is significantly different (p < 0.05) for men compared with women of the same age group, based on a two-tailed t test.
2 Visit rate is significantly different (p < 0.05) compared with all persons aged 18–29, based on a two-tailed t test.
3 Visit rate is significantly different (p < 0.05) compared with men aged 50–64, based on a two-tailed t test.
4 Visit rate is significantly different (p < 0.05) compared with all persons aged 50–64, based on a two-tailed t test.
Figure is based on 3-year averages. Emergency department visits related to schizophrenia are defined as code 295 of the International Classification of Diseases, Ninth Revision, Clinical Modification for any of the up to three collected visit diagnoses. Data are based on a sample of 551 emergency department visits related to schizophrenia made during 2009–2011, representing an average weighted total of 382,000 visits per year. Visit rates are based on the set of estimates of the civilian noninstitutionalized population of the United States, as developed by the U.S. Census Bureau’s Population Division.

Data Source: CDC/NCHS, National Hospital Ambulatory Medical Care Survey, 2009–2011.

Source: Centers for Disease Control and Prevention/National Center for Health Statistics: Emergency Department Visits Related to Schizophrenia Among Adults Aged 18–64: United States, 2009–2011

Mean Percentage of Calories from Fast Food among Children

Notes: 1 Significantly different from non-Hispanic white, non-Hispanic black, and Hispanic children (p < 0.05).
2 Significantly different from non-Hispanic white and non-Hispanic black children (p < 0.05).

Data Source: CDC/NCHS, National Health and Nutrition Examination Survey, 2011–2012.

Source: Centers for Disease Control and Prevention/National Center for Health Statistics: Caloric Intake From Fast Food Among Children and Adolescents in the United States, 2011–2012

Physician Office Visits per 100 Persons, 2012

Notes: 1 Visit rate is statistically significantly higher (p < 0.05) for females compared with males, based on a two-tailed t test.
2 Visit rate is statistically significantly higher (p < 0.05) for age 65 and over compared with under age 18 and 18–64, based on a two-tailed t test.
Data for 2012 are based on a sample of 76,330 physician office visits, representing an estimated weighted total of 928.6 million visits. Includes visits to nonfederal, office-based physicians. Excludes physicians in community health centers, anesthesiologists, radiologists, and pathologists. For more information, see the 2012 NAMCS microdata file documentation. Visit rates per 100 persons are based on estimates from special tabulations developed by the Population Division, U.S. Census Bureau using the July 1, 2012, set of state population estimates and reflect Census 2010 data. More information may be obtained from the U.S. Census Bureau website.

Data Source: CDC/NCHS, National Ambulatory Medical Care Survey, 2012.

Source: Centers for Disease Control and Prevention/National Center for Health Statistics: Variation in Physician Office Visit Rates by Patient Characteristics and State, 2012

Total Knee Replacement among Inpatients Aged 45 and Over

Notes: 1 Significant difference in 2000 between men and women within age group (p < 0.05).
2 Significant difference between 2000 and 2010 within sex and age group (p < 0.05).
3 Significant difference in 2010 between men and women within age group (p < 0.05).
Total knee replacement is defined as code 81.54 of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD–9–CM) for any of four collected procedures. Rates were calculated using U.S. Census Bureau 2000-based postcensal civilian population estimates.

Data Source: CDC/NCHS, National Hospital Discharge Survey, 2000 and 2010.

Source: Centers for Disease Control and Prevention/National Center for Health Statistics: Hospitalization for Total Knee Replacement Among Inpatients Aged 45 and Over: United States, 2000–2010

Median Medicaid/CHIP Income Eligibility Levels, as a Percent of the FPL

Notes: State-reported eligibility levels as of Jan. 2015, updated to reflect Medicaid expansion implementation as of Sept. 2015. Data do not reflect other eligibility changes made since Jan. 2015. MT has adopted the Medicaid expansion but it has not yet been implemented. Eligibility levels include the standard five percentage point of the federal poverty level (FPL) disregard. As of 2015, the FPL was $20,090 for a family of three and $11,770 for an individual.

Data Source: Based on results from a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2015, with additional data updates.

Source: Kaiser Family Foundation: Median Medicaid/CHIP Income Eligibility Levels by Group

Children with Diagnosed ADHD, by Race and Ethnicity

Notes: Among children 5–17 years of age.
Based on responses to the question, “Has a doctor or health professional ever told you that (child) had attention-deficit/hyperactivity disorder (ADHD) or attention deficit disorder (ADD)?”
Estimates are based on household interviews of a sample of the civilian noninstitutionalized U.S. population and are derived from the National Health Interview Survey’s Sample Child component.

Data Source: National Center for Health Statistics, CDC. National Health Interview Survey.

Source: Centers for Disease Control and Prevention: Percentage of Children and Adolescents Aged 5–17 Years with Diagnosed Attention-Deficit/Hyperactivity Disorder (ADHD), by Race and Hispanic Ethnicity — National Health Interview Survey, United States, 1997–2014

State Cigarette Excise Tax Rates

Notes: Map shows all cigarette tax rates in effect as of August 1st, 2015.
Tax rates are per pack of 20 cigarettes. The median tax rate in the United States is $1.53 per pack. The average price for a pack of cigarettes in the United States is roughly $6.24.
Alabama, California, Colorado, Georgia, Idaho, Maine, Michigan, Missouri, Montana, Nebraska, North Dakota, Oklahoma, Virginia, West Virginia, and Wyoming last increased their cigarette taxes in 2005 or earlier.
Federal cigarette tax is $1.01 per pack.

Data Source: Campaign for Tobacco Free Kids, State Cigarette Excise Tax Rates & Rankings, August 1st, 2015.

Source: Kaiser Family Foundation: State Cigarette Excise Tax Rates

Percentage of Young Adults with a Usual Place of Care

Notes: Among adults 19–25 years of age.
Based on a question in the Sample Adult section that asked, “Is there a place that you usually go to when you are sick or need advice about your health?” Adults who indicated that the emergency department was their usual place for care were considered not to have a usual place of health care.
Categories shown are for non-Hispanic respondents who selected one racial group; respondents had the option to select more than one racial group. Hispanic origin refers to persons who are of Hispanic ethnicity and might be of any race or combination of races. Only selected groups shown in graph.
Estimates are based on household interviews of a sample of the civilian, noninstitutionalized U.S. population and are derived from the Sample Adult component.
Percentages shown with 95% confidence intervals.

Data Source: National Health Interview Survey.

Source: Centers for Disease Control and Prevention: Percentage of Adults Aged 19–25 Years with a Usual Place of Care, by Race/Ethnicity — National Health Interview Survey, United States, 2010 and 2014

Annual Rate of Alcohol-Impaired Driving Episodes per 1,000 Population

Notes: Self-reported, among adults.
Abbreviation: DC = District of Columbia.
Rates were suppressed if sample size was <50 or relative standard error was >30%.

Data Source: 2012 Behavioral Risk Factor Surveillance System survey.

Source: Centers for Disease Control and Prevention: Alcohol-Impaired Driving Among Adults — United States, 2012

Coverage Distribution of Insured Adults by Race and Ethnicity

Notes: * Indicates statistically significant difference from White, Non-Hispanic at p < 0.05 level. Other includes Medicare, those that reported they were insured but did not specify types of coverage, and those that reported other.

Data Source: 2014 Kaiser Survey of Low-Income Americans and the ACA.

Source: Kaiser Family Foundation: Racial and Ethnic Disparities in Access to and Utilization of Care among Insured Adults

Trends in Observed Inpatient Mortality

Note: Abbreviations: AMI, acute myocardial infarction; CHF, congestive heart failure.

Data Sources: Agency for Healthcare Research and Quality (AHRQ), Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project (HCUP), Nationwide Inpatient Sample (NIS), 2002-2011; State Inpatient Databases (SID), 2012, weighted to provide national estimates using the same methodology as the 2002-2011 NIS; and the AHRQ Quality Indicators, version 4.4.

Source: Agency for Healthcare Research and Quality/Healthcare Cost and Utilization Project: Trends in Observed Adult Inpatient Mortality for High-Volume Conditions, 2002-2012

Death Rates from Cancer, by Region

Notes: Death rates are per 100,000 standard 2000 population and are age-adjusted.
Cancer deaths are identified using underlying cause of death with codes 140–209 (1970–1978), 140–208 (1979–1998) and C00–C97 (1999–2013) in the International Classification of Diseases, Eighth, Ninth, and Tenth Revision.
Northeast: Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, New Jersey, New York, Pennsylvania, and Vermont; Midwest: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin; South: Alabama, Arkansas, Delaware, Florida, Georgia, Kentucky, Louisiana, Mississippi, Maryland, North Carolina, Oklahoma, South Carolina, Virginia, Tennessee, Texas, West Virginia, and District of Columbia; West: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming.

Data Source: National Vital Statistics System. Mortality public use data files, 1970–2013.

Source: Centers for Disease Control and Prevention: Age-Adjusted Death Rates from Cancer, by U.S. Census Region and Year — United States, 1970–2013

Annual Birth Rates, by Marital Status

Notes: Births per 1,000 women aged 15–44 years in each category. Data for 2014 are preliminary.

Data Source: Hamilton B, Martin J, Osterman M, Curtin S. Births: preliminary data for 2014. Natl Vital Stat Rep 2015;64(6).

Source: Centers for Disease Control and Prevention: Annual Birth Rates, by Marital Status — National Vital Statistics System, United States, 1980–2014

Provider Counseling on Sexual Health Topics among Women

Notes: Among women ages 15-44. For women ages 18+, have discussed within the past 3 years. For women ages 15-17, have discussed within past 12 months.
*Indicates a statistically significant difference from Private insurance, p < 0.05.

Data Source: Kaiser Family Foundation, 2013 Kaiser Women’s Health Survey.

Source: Kaiser Family Foundation: Medicaid and Family Planning: Background and Implications of the ACA

Annual Stroke Mortality among Adults Aged 45 and Above

Notes: 1 Significantly higher than the rates for other race and ethnicity groups.
2 Significantly higher than the rate for women of the same race and ethnicity.
3 Significantly lower than the rates for non-Hispanic white and black persons.
Average annual death rates, 2010–2013. Death rates are age-adjusted. Death rates for Hispanic and non-Hispanic Asian or Pacific Islander persons should be interpreted with caution because of inconsistencies in reporting Hispanic origin or race on the death certificate compared with population figures.

Data Source: CDC/NCHS, Compressed Mortality File, 1999–2013.

Source: Centers for Disease Control and Prevention/National Center for Health Statistics: Differences in Stroke Mortality Among Adults Aged 45 and Over: United States, 2010–2013

Observed and Projected Melanoma Rates

Notes: Rates are age-adjusted. Age-period-cohort regression models were used to project melanoma incidence and mortality rates through 2030.

Data Sources: Melanoma incidence data are from the Surveillance, Epidemiology, and End Results program for the period 1982–2011. Mortality data are provided by CDC’s National Center for Health Statistics for the period 1982–2011.

Source: Centers for Disease Control and Prevention: Melanoma Incidence and Mortality Trends and Projections — United States, 1982–2030

Employed Adults Who Had Paid Sick Leave

Notes: Based on responses to a question that asked, “Do you have paid sick leave on this MAIN job or business?”
Respondents were asked to identify the business or industry of their main job, and these industries/businesses were then categorized by the North American Industry Classification System.
Estimates were based on a sample of the U.S. civilian, noninstitutionalized population aged ≥18 years. Adults not currently employed at the time of interview were not included in the denominators when calculating percentages.
¶ The percentage difference between women and men within this category was statistically significant at p < 0.01.

Data Source: National Health Interview Survey, 2009–2013.

Source: Centers for Disease Control and Prevention: Percentage of Currently Employed Adults Who Had Paid Sick Leave, by Industry — National Health Interview Survey, United States, 2009–2013

Adults Who Met Guidelines for Aerobic Activity and Muscle Strengthening

Notes: Guidelines for aerobic activity and muscle strengthening per U.S. Department of Health and Human Services 2008 Physical Activity Guidelines for Americans. Available at http://www.health.gov/paguidelines/guidelines/default.aspx. Respondents defined as meeting both aerobic-activity and muscle-strengthening guidelines reported moderate-intensity physical activity for ≥150 minutes per week, vigorous-intensity physical activity for ≥75 minutes per week, or an equivalent combination of moderate- and vigorous-intensity activity, and engaging in physical activities specifically designed to strengthen muscles at least twice per week.
Estimates are based on household interviews of a sample of the civilian, noninstitutionalized U.S. population and are derived from the National Health Interview Survey sample adult component.
§ 95% confidence interval.

Data Source: CDC. National Health Interview Survey data, 2008 and 2013.

Source: Centers for Disease Control and Prevention: Percentage of Adults Aged ≥18 Years Who Met National Guidelines for Aerobic Activity and Muscle Strengthening, by Age Group — National Health Interview Survey, United States, 2008 and 2013

Uninsured Rates among Low-Income Adults

Note: The following states expanded their Medicaid program and began enrolling individuals in March 2015 or earlier: AR, AZ, CA, CO, CT, DE, HI, IA, IN, IL, KY, MA, MD, MI, MN, ND, NH, NJ, NM, NV, NY, OH, OR, PA, RI, VT, WA, WV, and the District of Columbia. All other states were considered to have not expanded.

Data Source: The Commonwealth Fund Affordable Care Act Tracking Surveys, July–Sept. 2013, April–June 2014, and March–May 2015.

Source: The Commonwealth Fund: Americans’ Experiences with Marketplace and Medicaid Coverage

Cost Barriers to Use of Preventive Services

Notes: Among women and men ages 18-64. Federal Poverty Level (FPL) was $19,530 for a family of three in 2013.
* Indicates a statistically significant difference from Insured and 200% FPL or greater, p<0.05.

Data Source: Kaiser Family Foundation, 2013 Kaiser Women’s Health Survey.

Source: Kaiser Family Foundation: Preventive Services Covered by Private Health Plans under the Affordable Care Act

Children with a Communication Disorder During the Past Year

Notes: Among children aged 3–17 years. Data are based on household interviews with parents or adult caregivers of children in a sample of the civilian noninstitutionalized U.S. population. Children could have more than one type of communication disorder.

Data Source: CDC/NCHS, National Health Interview Survey, 2012.

Source: Centers for Disease Control and Prevention/National Center for Health Statistics: Communication Disorders and Use of Intervention Services Among Children Aged 3–17 Years: United States, 2012

Death Rates from Dementia

Notes: Death rates per 100,000 population. Deaths from dementia include underlying and contributing causes of death coded F01 (vascular dementia), F03 (unspecified dementia) or G30 (Alzheimer’s disease) according to the International Classification of Diseases, 10th Revision.

Data Source: National Vital Statistics System. Multiple cause of death data, 2000–2013.

Source: Centers for Disease Control and Prevention: Death Rates from Dementia Among Persons Aged ≥75 Years, by Sex and Age Group — United States, 2000–2013

Share of Resource Use and Outcomes for Super-Utilizers

Note: a Super-utilizers are Medicare and Medicaid patients with four or more hospital stays and privately insured patients with three or more hospital stays in 2012.

Data Source: Weighted national estimates from the Agency for Healthcare Research and Quality (AHRQ), Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project (HCUP), Nationwide Readmissions Database (NRD), 2012.

Source: Agency for Healthcare Research and Quality/Healthcare Cost and Utilization Project: Characteristics of Hospital Stays for Super-Utilizers by Payer, 2012

Maternal Morbidity, by Method of Delivery

Notes: 1 Difference in rates between primary cesarean and VBAC is not statistically significant.
The birth certificate reporting area represented 90% of all U.S. births in 2013. ICU is intensive care unit.

Data Source: CDC/NCHS, National Vital Statistics System.

Source: Centers for Disease Control and Prevention/National Center for Health Statistics: Maternal Morbidity for Vaginal and Cesarean Deliveries, According to Previous Cesarean History: New Data From the Birth Certificate, 2013

Medicaid Spending and Enrollment Growth

Notes: Enrollment percentage changes from June to June of each year. Spending growth percentages in state fiscal year.

Data Source: Medicaid Enrollment June 2013 Data Snapshot, KCMU, January 2014. Spending Data from KCMU Analysis of CMS Form 64 Data for Historic Medicaid Growth Rates. FY 2014 and 2015 data based on KCMU survey of Medicaid officials in 50 states and DC conducted by Health Management Associates, October 2014.

Source: Kaiser Family Foundation: Medicaid Financing: How Does it Work and What are the Implications?

Percent of Adults Insured All Year Who Were Underinsured

Notes: Among adults ages 19–64. Underinsured defined as insured all year but experienced one of the following: out-of-pocket expenses equaled 10% or more of income; out-of-pocket expenses equaled 5% or more of income if low income (<200% of poverty); or deductibles equaled 5% or more of income.

Data Source: The Commonwealth Fund Biennial Health Insurance Surveys (2003, 2005, 2010, 2012, and 2014).

Source: The Commonwealth Fund: The Problem of Underinsurance and How Rising Deductibles Will Make It Worse: Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2014

Older Adults with Limitations in Certain Daily Activities

Data Source: U.S. Department of Health and Human Services (based on data from U.S. Census Bureau’s American Community Survey, Centers for Medicare & Medicaid Services’ Medicare Current Beneficiary Survey, National Center for Human Statistics, including the NCHS Health Data Interactive data warehouse).

Source: U.S. Government Accountability Office: Older Adults: Federal Strategy Needed to Help Ensure Efficient and Effective Delivery of Home and Community-Based Services and Supports

Children with Diagnosed ADHD

Notes: 1 Significantly different from girls within the same age group (p < 0.05). 2 Significantly different from all children aged 6–11 (p < 0.05). 3 Significantly different from all children aged 12–17 (p < 0.05). 4 Significantly different from children of the same sex aged 6–11 (p < 0.05). 5 Significantly different from children of the same sex aged 12–17 (p < 0.05). Data are based on household interviews of a sample of the civilian noninstitutionalized U.S. population. ADHD is attention deficit hyperactivity disorder.

Data Source: CDC/NCHS, National Health Interview Survey, 2011–2013.

Source: Centers for Disease Control and Prevention/National Center for Health Statistics: Association Between Diagnosed ADHD and Selected Characteristics Among Children Aged 4–17 Years: United States, 2011–2013

Percentage of Adults Up-to-Date with Cancer Screening

Notes: CRC = colorectal cancer; Pap = Papanicolaou.
* Among women aged 21–65 years with no previous hysterectomy. Pap test data for 2003 were excluded because hysterectomy status was not ascertained in that year.
† Among women aged 50–74 years.
§ Among persons aged 50–75 years.

Data Sources: National Health Interview Survey, 2000, 2003, 2005, 2008, 2010, and 2013.

Source: Centers for Disease Control and Prevention: Cancer Screening Test Use — United States, 2013

Adults Who Did Not Take Medication as Prescribed to Save Money

Notes: Among those prescribed medication during the preceding 12 months.
Based on a positive response to any of the following three survey questions: “You skipped medication doses to save money; you took less medicine to save money; or you delayed filling a prescription to save money.” In 2013, these questions were asked to those who reported having been prescribed medication by a doctor or other health professional during the preceding 12 months, and referred to actions to save money during the preceding 12 months.
Estimates are based on household interviews of a sample of the civilian noninstitutionalized U.S. population and are derived from the National Health Interview Survey Sample Adult component.
§ 95% confidence interval.

Data Source: National Health Interview Survey, 2013.

Source: Centers for Disease Control and Prevention: Percentage of Adults Who Did Not Take Medication as Prescribed to Save Money, Among Those Prescribed Medication During the Preceding 12 Months, by Sex and Age Group — National Health Interview Survey, United States, 2013

Change in Total Medicaid and CHIP Enrollment

Notes: Summer 2013 enrollment data based on monthly average for July-Sept. 2013. Data not available for CT and ME for the entire reporting period. Data are not available for ND for Feb-Jun 14 and for VT for Nov 14. “States with Medicaid expansion in effect” changes over time to reflect adoption of the expansion in MI (Apr 14), NH (Jul 14) and PA (Jan 15). IN, which expanded Feb 1, 2015, is in the “States with Medicaid Expansion Not in Effect” calculation for all periods.

Data Sources: CMS, Medicaid & CHIP: Monthly Application and Eligibility Reports, October 2013 – January 2015.

Source: Kaiser Family Foundation: Recent Trends in Medicaid and CHIP Enrollment as of January 2015: Early Findings from the CMS Performance Indicator Project

Suicide Rates by Urbanization of County of Residence

Notes: Age-adjusted rates per 100,000, based on the 2000 U.S. standard population. Suicides are coded as *U03, X60–X84, and Y87.0 in the International Classification of Diseases, 10th Revision.
Counties were classified into urbanization levels based on a classification scheme that considers metropolitan/nonmetropolitan status, population, and other factors.
§ 95% confidence interval.

Data Sources: National Vital Statistics System. County-level mortality file.
Ingram DD, Franco SJ. 2013 NCHS urban-rural classification scheme for counties. Vital Health Stat 2014;2(166).

Source: Centers for Disease Control and Prevention: Age-Adjusted Rates for Suicide, by Urbanization of County of Residence — United States, 2004 and 2013

Percentage of Adults Who Average Six or Fewer Hours of Sleep

Notes: Participants were asked, “On average, how many hours of sleep do you get in a 24-hour period?”
Family income groups were defined based on family income as a percentage of the federal poverty threshold. Poverty thresholds, which are published by the U.S. Census Bureau, vary by family size and the number of children in the family. Family income was imputed when missing using multiple imputation methodology.
Metropolitan status of residence was based on the household residence location. Metropolitan is located within a metropolitan statistical area, defined as a county or group of contiguous counties that contains at least one urbanized area of ≥50,000 population. Surrounding counties with strong economic ties to the urbanized area also are included. Nonmetropolitan areas do not include a large urbanized area and are generally thought of as more rural.
Estimates are based on household interviews of a sample of the civilian, noninstitutionalized U.S. population and are derived from the National Health Interview Survey sample adult component.
** 95% confidence interval.

Data Source: National Health Interview Survey, 2013 data.

Source: Centers for Disease Control and Prevention: Percentage of Adults Who Average ≤6 Hours of Sleep, by Family Income Group and Metropolitan Status of Residence — National Health Interview Survey, United States, 2013

Prevalence of Chronic Obstructive Pulmonary Disease among Adults

Notes: Age-adjusted to the 2000 U.S. standard population aged ≥18 years.
Based on a positive response to the question, “Have you ever been told by a doctor or health professional that you have COPD, emphysema, or chronic bronchitis?”

Data Source: 2013 Behavioral Risk Factor Surveillance System survey.

Source: Centers for Disease Control and Prevention: Employment and Activity Limitations Among Adults with Chronic Obstructive Pulmonary Disease — United States, 2013

Medicare Hospital Readmission Rates

Notes: National readmission rates include Medicare fee-for-service unplanned hospitalizations for any cause within 30 days of discharge from an initial hospitalization for either heart failure, heart attack, or pneumonia. Rates are risk-adjusted for certain patient characteristics, such as age and other medical conditions.

Data Source: Kaiser Family Foundation analysis of CMS Hospital Compare data files.

Source: Kaiser Family Foundation: A Primer on Medicare: Key Facts About the Medicare Program and the People it Covers

Hypertension-Related Death Rates

Notes: Linear increases from 2000 through 2013 for all male age groups and women aged 45–64 and 85 and over are statistically significant at the p < 0.05 level. Hypertension-related deaths are identified using ICD–10 codes I10, I11, I12, I13, and I15, according to the International Classification of Diseases, 10th revision (ICD–10).

Data Source: CDC/NCHS, National Vital Statistics System, Mortality.

Source: Centers for Disease Control and Prevention/National Center for Health Statistics: Hypertension-related Mortality in the United States, 2000–2013

Prevalence of Dental Caries among Children Aged 6–11 Years

Notes: * Does not meet standards of statistical reliability and precision (relative standard error of ≥ 30% but < 40%). 1 Includes untreated and treated (restored) dental caries. 2 Significantly different from those aged 9–11 years, p < 0.05. 3 Significantly different from Hispanic children, p < 0.05.

Data Source: CDC/NCHS, National Health and Nutrition Examination Survey, 2011–2012.

Source: Centers for Disease Control and Prevention/National Center for Health Statistics: Dental Caries and Sealant Prevalence in Children and Adolescents in the United States, 2011–2012

Adults Lacking a Usual Source of Care or Going without Care

Notes: Black and white refer to black and white non-Hispanic populations. Hispanics may identify as any race.

Data Source: 2012 and 2013 Behavioral Risk Factor Surveillance Survey (BRFSS).

Source: The Commonwealth Fund: Closing the Gap: Past Performance of Health Insurance in Reducing Racial and Ethnic Disparities in Access to Care Could Be an Indication of Future Results

Trends in Long-Acting Reversible Contraceptive Use, by Age

Notes: 1 Significantly less than women aged 25–34.
* Figure does not meet standards of reliability or precision; too few women aged 15–24 reported using long-acting reversible contraceptives in 1988.
Linear trends in use of long-acting reversible contraceptives for all age groups from 2002 to 2011–2013 are statistically significant.

Data Source: CDC/NCHS, National Survey of Family Growth, 1982, 1988, 1995, 2002, 2006–2010, and 2011–2013.

Source: Centers for Disease Control and Prevention/National Center for Health Statistics: Trends in Long-acting Reversible Contraception Use Among U.S. Women Aged 15–44

Homicide Rates by Urbanization of County of Residence

Notes: Age-adjusted rates per 100,000, based on the 2000 U.S. standard population. Deaths from homicide are coded *U01–*U02, X85–Y09, and Y87.1 in the International Classification of Diseases, 10th Revision.
Counties were classified into urbanization levels based on a classification scheme that considers metropolitan/nonmetropolitan status, population, and other factors.
§ 95% confidence interval.

Data Source: National Vital Statistics System.

Source: Centers for Disease Control and Prevention: Age-Adjusted Homicide Rates, by Urbanization of County of Residence — United States, 2004 and 2013

Use of Yoga in the Past Year

Notes: Error bars show 95% confidence interval.
1 Significantly different from 2007 and 2012 (p < 0.05).
2 Significantly different from 2012 (p < 0.05).
3 Significantly different from 2002 and 2007 (p < 0.05).
Estimates are based on household interviews of a sample of the civilian noninstitutionalized population.

Data Source: CDC/NCHS, National Health Interview Survey, 2002, 2007, and 2012.

Source: Centers for Disease Control and Prevention/National Center for Health Statistics: Trends in the Use of Complementary Health Approaches Among Adults: United States, 2002–2012

Emergency Department Visits for Motor Vehicle Traffic Injuries

Notes: 1 Visit rate for non-Hispanic black persons is significantly different (p < 0.05) from non-Hispanic white persons and Hispanic persons based on a two-tailed t test. 2 Visit rate for Hispanic persons is significantly different (p < 0.05) from non-Hispanic white persons and non-Hispanic black persons for the age group 16–24 based on a two-tailed t test. Figures are based on 2-year averages. Visit rates are based on the July 1, 2010, and July 1, 2011, set of estimates of the civilian noninstitutionalized population of the United States, as developed by the Population Division, U.S. Census Bureau.

Data Source: CDC/NCHS, National Hospital Ambulatory Medical Care Survey, 2010–2011.

Source: Centers for Disease Control and Prevention/National Center for Health Statistics: Emergency Department Visits for Motor Vehicle Traffic Injuries: United States, 2010–2011

Health Status among Nonelderly Adults, by Insurance Coverage

Notes: Interviews conducted in Fall 2014. Includes adults ages 19-64. “Continuously Insured” includes people who were insured as of interview date and have been insured since before January 2014. “Newly Insured” include people who were insured as of interview date and gained coverage since January 2014. “Uninsured” includes people who lacked coverage as of the interview date.
^Does not include birth control.
*Significantly different from Uninsured at the p<0.05 level.

Data Source: 2014 Kaiser Survey of Low-Income Americans and the ACA.

Source: Kaiser Family Foundation: Adults who Remained Uninsured at the End of 2014

Deaths from Cervical Cancer

Notes: Age-adjusted rates (deaths per 100,000) based on the 2000 U.S. standard population. Populations used for computing death rates for 2011–2013 are postcensal estimates based on the 2010 census, estimated as of July 1, 2013. Rates for census years are based on populations enumerated in the corresponding censuses. Rates for noncensus years before 2010 are revised using updated intercensal population estimates and might differ from rates previously published.
Malignant neoplasm of cervix uteri (International Classification of Diseases, 10th Revision [ICD-10] code C53) as the underlying cause of death includes the following ICD-10 codes: endocervix (C53.0), exocervix (C53.1), overlapping lesion of cervix uteri (C53.8), and cervix uteri, unspecified (C53.9).

Data Source: National Vital Statistics System. Mortality public use data files, 2013.

Source: Centers for Disease Control and Prevention: Death Rates for Cervical Cancer — National Vital Statistics System, United States, 1999–2013

Population Residing in Primary Care Health Professional Shortage Areas

Notes: Includes populations in Geographic Area and Population Group Health Professional Shortage Areas (HPSAs), but not Facility HPSAs.
*HRSA data show no population living in Geographic or Population Group Primary Care HPSAs in NJ and VT.

Data Source: KCMU analysis based on HRSA Designated Primary Care Health Professional Shortage Area Statistics as of August 12, 2014 and the March 2014 Annual Social and Economic (ASEC) Supplement to the Current Population Survey (CPS).

Source: Kaiser Family Foundation: Tapping Nurse Practitioners to Meet Rising Demand for Primary Care

Percentage of Persons Living with HIV, by Outcome

Notes: Out of an estimated 1.2 million persons living with HIV infection in the United States in 2011.
HIV = human immunodeficiency virus; ART = antiretroviral therapy.

Data Sources: The National HIV Surveillance System and the Medical Monitoring Project.

Source: Centers for Disease Control and Prevention: HIV Diagnosis, Care, and Treatment Among Persons Living with HIV — United States, 2011

Alcohol Poisoning Deaths per 1 Million ≥15 Years

Notes: Alcohol poisoning deaths included those occurring among those aged ≥15 years in which alcohol poisoning was classified as the underlying (i.e., principal) cause of death based on International Classification of Diseases, 10th Revision (ICD-10) codes X45 (accidental poisoning by and exposure to alcohol) and Y15 (poisoning by and exposure to alcohol, undetermined intent).
Rates per 1 million population for persons aged ≥15 years were calculated using U.S. Census bridged-race population for 2010–2012, and were age-adjusted to the 2000 U.S. Census standard population.
The average annual number of alcohol poisoning deaths in Delaware, District of Columbia, Hawaii, North Dakota, and Vermont was less than seven and therefore, did not meet standards of reliability and precision to calculate age-adjusted death rates.

Data Source: National Vital Statistics System.

Source: Centers for Disease Control and Prevention: Alcohol Poisoning Deaths — United States, 2010–2012

Death Rates from Viral Hepatitis

Notes: Deaths from viral hepatitis include underlying and contributing causes coded as B15–B19 in the International Classification of Diseases, 10th Revision.

Data Sources: CDC. National Vital Statistics System and Health Data Interactive.

Source: Centers for Disease Control and Prevention: Death Rates from Viral Hepatitis Among Adults Aged ≥18 Years, by Age Group and Sex — National Vital Statistics System, United States, 1999–2011

Distribution of Individuals Covered by Private Health Insurance

Notes: Distribution by type of health plan.
a Traditional = Health plan with no deductible or <$1,250 (individual), <$2,500 (family) in 2014.
b HDHP = High-deductible health plan with deductible $1,250+ (individual), $2,500+ (family), not HSA-eligible in 2014.
c CDHP = Consumer-driven health plan with deductible $1,250+ (individual), $2,500+ (family), with HRA, HSA, or HSA-eligible in 2014.

Data Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005‒2007; EBRI/Greenwald & Associates Consumer Engagement in Health Care Survey, 2008‒2014.

Source: Employee Benefit Research Institute: Findings from the 2014 EBRI/Greenwald & Associates Consumer Engagement in Health Care Survey

Medicare Spending per Beneficiary

Notes: Medicare spending equals payments for benefits, net of recoveries from providers for improper payments, adjusted for shifts in the timing of capitated payments. Years are federal fiscal years, which run from October through September.

Data Source: RAND/Kaiser Family Foundation analysis of Congressional Budget Office, actual Medicare benefit payments, various years. Medicare Trustees historical enrollment (through 2013) and projected for 2014 from the 2014 Medicare Trustees report (enrollees in the Hospital Insurance program).

Source: Kaiser Family Foundation: How Much of the Medicare Spending Slowdown Can be Explained? Insights and Analysis from 2014

Prevalence of Current Cigarette Smoking among Adults

Notes: Data are based on household interviews of a sample of the civilian noninstitutionalized population. Current cigarette smokers were defined as those who had smoked more than 100 cigarettes in their lifetime and now smoke every day or some days. The analyses excluded persons with unknown cigarette smoking status (about 2% of respondents each year).

Data Source: CDC/NCHS, National Health Interview Survey, 1997–June 2014, Sample Adult Core component.

Source: Centers for Disease Control and Prevention/National Center for Health Statistics: Early Release of Selected Estimates Based on Data From the January–June 2014 National Health Interview Survey

Prevalence of Diagnosed Diabetes among Adults

Notes: Data are based on household interviews of a sample of the civilian noninstitutionalized population. Prevalence of diagnosed diabetes is based on self-report of ever having been diagnosed with diabetes by a doctor or other health professional. Persons reporting “borderline” diabetes status and women reporting diabetes only during pregnancy were not coded as having diabetes in the analyses. The analyses excluded persons with unknown diabetes status (about 0.1% of respondents each year).

Data Source: CDC/NCHS, National Health Interview Survey, 1997–June 2014, Sample Adult Core component.

Source: Centers for Disease Control and Prevention/National Center for Health Statistics: Early Release of Selected Estimates Based on Data From the January–June 2014 National Health Interview Survey

Percentage of Persons with Depression

Notes: Depression is defined as having moderate to severe depressive symptoms.
1 Males have significantly lower rates than females overall and in every age group.
2 Significantly different from 40–59.
3 Significantly different from 18–39.
4 Significantly different from 60 and over.

Data Source: CDC/NCHS, National Health and Nutrition Examination Survey, 2009–2012.

Source: Centers for Disease Control and Prevention/National Center for Health Statistics: Depression in the U.S. Household Population, 2009–2012

Percentage of Mental Health-Related Primary Care Visits

Notes: A mental health visit was defined by at least one of the following: ordering or provision of depression screening, psychotherapy, or other mental health counseling; a mental health diagnosis or reason for visit; or a psychotropic medication that was ordered, supplied, administered, or continued at the visit. Mental health diagnosis, reason for visit, and psychotropic medications were based on certain categories. Source: Olfson M, Kroenke K, Wang S, Blanco C. Trends in office-based mental health care provided by psychiatrists and primary care physicians. J Clin Psychiatry 2014;75:247–53.
Includes physicians in primary care specialties: general and family practice, internal medicine, pediatrics, and obstetrics/gynecology.
§ 95% confidence interval.

Data Source: 2010 National Ambulatory Medical Care Survey.

Source: Centers for Disease Control and Prevention: Percentage of Mental Health–Related Primary Care Office Visits, by Age Group — National Ambulatory Medical Care Survey, United States, 2010

State Health Insurance Marketplace Types, 2015

Notes: This map displays the marketplace type for the individual market. For most states, the marketplace type is the same for the small business, or SHOP, marketplace; however, MS, NM, and UT operate State-based SHOP Marketplaces.

Data Source: State Health Insurance Marketplace Types, 2015, KFF State Health Facts.

Source: Kaiser Family Foundation: State Health Insurance Marketplace Types

Perinatal Mortality Rates, 2010–2011

Notes: Perinatal mortality rate is the number of infant deaths under age 7 days and fetal deaths at 28 weeks of gestation or more per 1,000 live births and fetal deaths at 28 weeks of gestation or more.

Data Sources: CDC/NCHS, National Vital Statistics System.

Source: Centers for Disease Control and Prevention/National Center for Health Statistics: Trends in Fetal and Perinatal Mortality in the United States, 2006–2012

Spending on Medical Out-of-Pocket Costs

Notes: FPL refers to federal poverty level.
* Respondent reported having at least one of the following chronic conditions: hypertension or high blood pressure; heart disease; diabetes; asthma, emphysema, or lung disease; high cholesterol; or depression or anxiety.
Base: Respondents who were insured all year and reported their income level and out-of-pocket costs.

Data Sources: The Commonwealth Fund Health Care Affordability Tracking Survey, September–October 2014.

Source: The Commonwealth Fund: Too High a Price: Out-of-Pocket Health Care Costs in the United States

Total Medicare Advantage Enrollment

Notes: Includes MSAs, cost plans and demonstrations. Includes Special Needs Plans as well as other Medicare Advantage plans.

Data Sources: Analysis by the Kaiser Family Foundation of publicly-available CMS Medicare Advantage enrollment files, 2007-2014.

Source: Kaiser Family Foundation: What Do We Know About Health Care Access and Quality in Medicare Advantage Versus the Traditional Medicare Program?

National Health Expenditures per Capita

Notes: According to CMS, population is the U.S. Bureau of the Census resident-based population, less armed forces overseas and their dependents.

Data Sources: Kaiser Family Foundation calculations using NHE data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group.

Source: Kaiser Family Foundation: National Health Expenditures per Capita, 1960-2023

Percentage of Adults Who Have Been Tested for HIV

Notes: HIV = human immunodeficiency virus.
Based on response to the question, “Except for tests you may have had as part of blood donations, have you ever had blood tested for the AIDS virus infection?”
Since 2006, CDC has recommended that all patients aged 13–64 years in any health care setting should be tested for HIV, regardless of the number of sex partners.
§ 95% confidence interval.

Data Sources: Woodring JV, Kruszon-Moran D, Oster AM, McQuillan GM. Did CDC’s 2006 revised HIV testing recommendations make a difference? Evaluation of HIV testing in the U.S. household population, 2003–2010. J Acquir Immune Defic Syndr 2014;67:331–40.

Source: Centers for Disease Control and Prevention: Percentage of Adults Aged 18–59 Years Who Have Ever Been Tested for HIV, by Number of Lifetime Sex Partners and by Sex — National Health and Nutrition Examination Survey, 2007–2010

Percentage of U.S. Children Enrolled in CHIP

Notes: The total does not add up to 100 percent because some children have multiple sources of health insurance over the course of a year, and the figure does not include those covered under TRICARE, the Indian Health Service, or nongroup insurance. Data for children’s Medicaid enrollment were not available from the Kaiser Family Foundation after 2010.

Data Sources: U.S. Census Bureau, Kaiser Family Foundation’s State Health Facts, Medicaid Statistical Information System, Statistical Enrollment Data System, and U.S. Department of Health and Human Services.

Source: The Pew Charitable Trusts/MacArthur Foundation: The Children’s Health Insurance Program: A 50-state examination of CHIP spending and enrollment

Percentage of Kindergarteners with Vaccine Exemptions

Notes: Exemptions might not reflect a child’s vaccination status. Children with an exemption who did not receive any vaccines are indistinguishable from those who have an exemption but are up-to-date for one or more vaccines.
MMR coverage is defined as coverage with 2 doses of measles, mumps, and rubella (MMR) vaccine.

Data Sources: School vaccination data collected by federally funded state, local, and territorial immunization programs.

Source: Centers for Disease Control and Prevention: Vaccination Coverage Among Children in Kindergarten — United States, 2013–14 School Year

States Implementing the Medicaid Expansion

Notes: Data are as of August 28, 2014. *AR, IA, MI, and PA have approved Section 1115 waivers for Medicaid expansion. In PA, coverage will begin in January 2015. NH is implementing the Medicaid expansion, but the state plans to seek a waiver at a later date. IN has a pending waiver to implement the Medicaid expansion. WI amended its Medicaid state plan and existing Section 1115 waiver to cover adults up to 100% FPL in Medicaid, but did not adopt the expansion.

Data Sources: Current status for each state is based on data from the Centers for Medicare and Medicaid Services and KCMU analysis of current state activity on Medicaid expansion.

Source: Kaiser Family Foundation: Implementing the ACA: Medicaid Spending & Enrollment Growth for FY 2014 and FY 2015

Health Care Law’s Perceived Impact on Americans

Notes: Survey question: As you may know, a number of the provisions of the healthcare law have already gone into effect. So far, has the new law — [ROTATED: helped you and your family, not had an effect, (or has it) hurt you and your family]?
Copyright © 2014 Gallup, Inc. All rights reserved. The content is used with permission; however, Gallup retains all rights of republication.

Data Sources: Gallup Daily tracking survey.

Source: Gallup: More Still Say Health Law Has Hurt Instead of Helped Them

Percentage of Adults with Serious Psychological Distress

Notes: GED = general educational development certification.
Serious psychological distress is based on responses to the questions, “During the past 30 days, how often did you feel 1) so sad that nothing could cheer you up, 2) nervous, 3) restless or fidgety, 4) hopeless, 5) that everything was an effort, or 6) worthless?” Response codes for the six items for each person were summed to yield a point value on a 0–24 point scale. A value of 13 or more was used to define serious psychological distress.
Estimates are based on household interviews of a sample of the noninstitutionalized U.S. civilian population. Estimates are age adjusted using the projected 2000 U.S. population as the standard population and using five age groups: 24–44 years, 45–54 years, 55–64 years, 65–74 years, and ≥75 years.
§ 95% confidence interval.

Data Sources: National Health Interview Survey.

Source: Centers for Disease Control and Prevention: Percentage of Adults Aged ≥25 Years with Serious Psychological Distress, by Education Level and Sex — National Health Interview Survey, United States, 2010–2013

Drug-Poisoning Death Rates

Notes: The number of drug-poisoning deaths in 2011 was 41,340, and the number of drug-poisoning deaths in 2011 involving opioid analgesics was 16,917. Access data table at: http://www.cdc.gov/nchs/data/databriefs/db166_table.pdf#1.

Data Sources: CDC/NCHS, National Vital Statistics System, Mortality File.

Source: Centers for Disease Control and Prevention/National Center for Health Statistics: Drug-poisoning Deaths Involving Opioid Analgesics: United States, 1999–2011

Children’s Risk of Dying Before 5 Years of Age

Notes: The classification is based on unrounded numbers. This map is stylized and not to scale. It does not reflect a position by UN IGME agencies on the legal status of any country or territory or the delimitation of any frontiers.

Data Sources: UN Inter-agency Group for Child Mortality Estimation.

Source: UNICEF: Levels and Trends in Child Mortality Report 2014

State Policies on Abortion Coverage

Notes: Arizona places restrictions on abortion coverage on plans sold on the Marketplace only.

Data Sources: Guttmacher Institute, State Policies in Brief: Restricting Insurance Coverage of Abortion, September 2014. National Conference of State Legislatures, Health Reform and Abortion Coverage in the Insurance Exchanges.

Source: Kaiser Family Foundation: Coverage for Abortion Services and the ACA

Percentage of Adults Aged 18-64 without Insurance

Notes: Estimates for 2014 are based on data collected from January through March. Data are based on household interviews of a sample of the civilian noninstitutionalized population.

Data Sources: CDC/NCHS, National Health Interview Survey, 1997–2014, Family Core component.

Source: Centers for Disease Control and Prevention National Center for Health Statistics: Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey, January–March 2014

Use of Complementary Health Approaches in Past Year

Notes: Complementary health approaches are based on the six most commonly used complementary health approaches among U.S. adults in 2012.
Metropolitan status of residence is based on the household residence location. Metropolitan is located within a metropolitan statistical area, defined as a county or group of contiguous counties that contains at least one urbanized area of ≥50,000 population. Surrounding counties with strong economic ties to the urbanized area also are included. Nonmetropolitan areas do not include a large urbanized area and are generally thought of as more rural.
Estimates are based on household interviews of a sample of the civilian noninstitutionalized U.S. population.
¶ 95% confidence interval.

Data Sources: National Health Interview Survey, 2012.

Source: Centers for Disease Control and Prevention: Percentage of Adults Who Used Selected Complementary Health Approaches in the Preceding 12 Months, by Metropolitan Status of Residence — National Health Interview Survey, United States, 2012

Percentage of Households with a Smokefree Home Rule

Notes: Households were considered to have a smokefree home rule if all adult respondents aged ≥18 years in the household reported that no one was allowed to smoke anywhere inside the home at any time.

Data Sources: Tobacco Use Supplement to the Current Population Survey, 1992–1993 and 2010–2011.

Source: Centers for Disease Control and Prevention: Prevalence of Smokefree Home Rules — United States, 1992–1993 and 2010–2011

Americans Extremely/Very Satisfied with Their Health Plan

Notes: a Traditional = Health plan with no deductible or <$1,000 (individual), <$2,000 (family).
b HDHP = High-deductible health plan with deductible $1,000+ (individual), $2,000+ (family), no account.
c CDHP = Consumer-driven health plan with deductible $1,000+ (individual), $2,000+ (family), with account.
* Difference between HDHP/CDHP and Traditional is statistically significant at p ≤ 0.05 or better.
^ Estimate is statistically different from the prior year shown at the p ≤ 0.05 or better.

Data Sources: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005–2007; EBRI/Greenwald & Associates Consumer Engagement in Health Care Survey, 2008–2013.

Source: Employee Benefit Research Institute: Satisfaction With Health Coverage and Care: Findings from the 2013 EBRI/Greenwald & Associates Consumer Engagement in Health Care Survey

Youth Reporting 2 Hours or Less of Screen Time Daily

Notes: † Significant linear trend by weight status, p < 0.05. TV plus computer is the sum of time spent watching TV and using a computer. For analytical purposes, the response of “< 1 hour” was assigned the value of 0.5 hours. Access data table at: http://www.cdc.gov/nchs/data/databriefs/db157_table.pdf#4.

Data Sources: CDC/NCHS, National Health and Nutrition Examination Survey (NHANES) and NHANES National Youth Fitness Survey, 2012.

Source: Centers for Disease Control and Prevention/National Center for Health Statistics: TV Watching and Computer Use in U.S. Youth Aged 12–15, 2012

Distribution of Weight Status among Adults with Diabetes

Note: * Weight status is based on body mass index cutoff values for adults (kg/m2): normal weight (18.5–24.9), overweight (25.0–29.9), and obese (≥30.0).
† Diabetes is defined as a fasting plasma blood glucose ≥126 mg/dL, a hemoglobin A1c ≥6.5%, or a self-reported physician diagnosis of diabetes.
§ Estimates are age-adjusted to year 2000 U.S. Census standard population using age groups 20–39 years, 40–59 years, and ≥60 years.
¶ 95% confidence interval.

Data Sources: CDC. National Health and Nutrition Examination Survey Data. Hyattsville, MD: US Department of Health and Human Services, CDC, National Center for Health Statistics; 2009–2012. Available at http://www.cdc.gov/nchs/nhanes.htm.

Source: Centers for Disease Control: QuickStats: Percentage Distribution of Weight Status* Among Adults Aged ≥20 Years with Diabetes,† by Sex — National Health and Nutrition Examination Survey, United States, 2009–2012§

Average Out of Pocket Expenses by Medicare Beneficiaries, 2010

Notes: Analysis excludes beneficiaries enrolled in Medicare Advantage plans. Premiums includes Medicare Parts A and B and other types of health insurance beneficiaries may have (Medigap, employer-sponsored insurance, and other public and private sources).

Data Sources: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey 2010 Cost & Use file

Source: Kaiser Family Foundation: How Much Is Enough? Out-of-Pocket Spending Among Medicare Beneficiaries: A Chartbook

Estimated Vaccination Coverage among Adolescents Aged 13–17 years, United States, 2006–2013

Note: Abbreviations: Tdap = tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis; MenACWY = meningococcal conjugate; HPV = human papillomavirus.
* ≥1 dose Tdap vaccine on or after age 10 years.
† ≥1 dose MenACWY vaccine.
§ HPV vaccine, either bivalent or quadrivalent, among females. The Advisory Committee on Immunization Practices (ACIP) recommends either bivalent or quadrivalent vaccine for females.
¶ HPV vaccine, either bivalent or quadrivalent, among males. ACIP recommends the quadrivalent vaccine for males; however, some males might have received bivalent vaccine.

Data Sources: Centers for Disease Control and Prevention

Source – Centers for Disease Control and Prevention: National, Regional, State, and Selected Local Area Vaccination Coverage among Adolescents Aged 13–17 Years — United States, 2013

Birth Rates for Females Aged 15-19 Years by Race/Ethnicity 1991-2013

Note: * Persons categorized as American Indian/Alaska Native or Asian/Pacific Islander also might be Hispanic. Data for 1991 and 1992 for the categories non-Hispanic black, non-Hispanic white, and Hispanic exclude data from New Hampshire, which did not report Hispanic ethnicity.
† Includes only U.S. residents.
§ Data for 2013 are preliminary.
The overall birth rate for females aged 15–19 years in the United States declined from 61.8 births per 1,000 in 1991 to 26.6 in 2013, a historic low. By racial/ethnic population, rates also declined to historic lows in 2013. Among non-Hispanic black females, the rate declined from 118.2 per 1,000 to 39.2; among Hispanic females, the rate declined from 104.6 to 41.9. Other declines were as follows: American Indians/Alaska Natives, from 84.1 to 31.2; non-Hispanic whites, from 43.4 to 18.7; and Asians/Pacific Islanders, from 27.3 to 8.8.

Data Sources: Hamilton BE, Martin JA, Osterman MJK, Curtin, SC. Births: preliminary data for 2013. Natl Vital Stat Rep 2014;63(2).

Source – Centers for Disease Control and Prevention: Morbidity and Mortality Weekly Report (MMWR)

Percentage of GDP Being Spent and Projected Spending on Medicare, Medicaid, CHIP, and Exchange Subsidies

Notes: The extended baseline generally reflects current law, following CBO’s 10-year baseline budget projections through 2024 and then extending the baseline concept for the rest of the long-term projection period.
CHIP = Children’s Health Insurance Program.
a. Net Medicare spending (includes offsetting receipts from premium payments by beneficiaries and amounts paid by states from savings on Medicaid’s prescription drug costs).

Data Sources: Congressional Budget Office

Source: Congressional Budget Office: The 2014 Long-Term Budget Outlook

Comparison of Average Net Unit Prices for the Sample Drugs, Third Quarter of 2010

Notes: aGAO used only federally mandated rebates when calculating Medicaid net prices. If state supplemental rebates had been applied, actual net prices paid by Medicaid would have been lower than the prices shown in the figure. GAO found that the state supplemental rebates, in aggregate, were equivalent to 4 percent of Medicaid expenditures for all drugs in the target quarter.
bThe Medicare Part D net prices are estimates because CMS allows Medicare Part D plan sponsors to use a variety of methods to allocate post-purchase price adjustments to the drug level and thus GAO could not definitively assign rebates to specific drugs.

Data Sources: GAO Analysis of Department of Defense (DOD) and Centers for Medicare & Medicaid Services (CMS) Data | GAO-14-578

Source: U.S. Government Accountability Office: Prescription Drugs: Comparison of DOD, Medicaid, and Medicare Part D Retail Reimbursement Prices

Growth in Marketplace Plan Selections in the FFM by Race/Ethnicity, 2-22-2014 to 3-29-2014

Notes: Represents the weekly growth rate (percentage increase) in the number of unique individuals who have been determined eligible to enroll in a plan through the FFM, and have selected a plan (with or without the first premium payment having been received by the issuer) by race/ethnicity.

Data Sources: Centers for Medicare & Medicaid Services, as of 4-29-2014

Source: Kaiser Family Foundation: Individual Market Enrollment Ticks Up in Early 2014

Number* and Percentage of Respiratory Specimens Testing Positive for Influenza, by Type, Subtype, Surveillance Week, and Year — World Health Organization and National Respiratory and Enteric Virus Surveillance System Collaborating Laboratories, United States, 2013–14 Influenza Season†

Notes: * N = 53,470.
† Data reported as of May 30, 2014.
Alternate Text: The figure above shows the number and percentage of respiratory specimens testing positive for influenza reported by type, subtype, surveillance week, and year in the United States during the 2013-14 influenza season. During September 29, 2013-May 17, 2014, World Health Organization and National Respiratory and Enteric Virus Surveillance System collaborating laboratories in the United States tested 308,741 specimens for influenza viruses; 53,470 (17.3%) were positive.

Data Source: Centers for Disease Control and Prevention

Source – Centers for Disease Control and Prevention: Influenza Activity — United States, 2013–14 Season and Composition of the 2014–15 Influenza Vaccines

Obesity Trends in Selected OECD Countries

Notes: Age- and gender-adjusted rates of obesity and overweight using the 2005 OECD standard population. Measured height and weight in Australia, England, Korea, Mexico and USA; self-reported data in other countries. No projection for Australia, Mexico and Switzerland since they were not produced in 2010.

Data Sources: OECD Estimates on National Health Surveys

Source: OECD: More Efforts Needed to Tackle Rising Obesity

Percentage of Uninsured Residents Eligible for Insurance Assistance in 2014

Notes: * Although Wisconsin has not accepted the ACA Medicaid expansion, adults up to 100% of FPL are now eligible for Medicaid and can enroll. Before 2014, there was a limited benefits program for low-income adult nonparents, but enrollment was closed.
+ Because Massachusetts has already implemented its own health reform law, the number of uninsured is not expected to change noticeably under the ACA.
± New Hampshire plans to expand Medicaid in July 2014.
• Pennsylvania and Indiana have submitted Medicaid expansion proposals that are pending CMS review.

Data Sources: Health Insurance Policy Simulation Model-American Community Suvey 2014.

Source: Robert Wood Johnson Foundation/Urban Institute: Eligibility for Assistance and Projected Changes in Coverage Under the ACA: Variation Across States

Lower Utilization of Screening Tests among Uninsured Women

Note: Among women ages 18-64. Mammogram screenings among women ages 40-64. Colon cancer screening among women ages 50-64. *Indicates a statistically significant different from Private insurance, p<.05.

Data Sources: Kaiser Family Foundation, 2013 Kaiser Women’s Health Survey.

Source – Kaiser Family Foundation: Women and Health Care in the Early Years of the Affordable Care Act

Vaccine Coverage Rates among Preschool-Aged Children* — United States, 1967–2012

Notes: Abbreviations: DTP/DTaP = diphtheria, tetanus, pertussis or diphtheria, tetanus, acellular pertussis; MMR = measles, mumps, and rubella; Hib = Haemophilus influenzae type b; Hep B = hepatitis B; PCV = pneumococcal conjugate vaccine; RV = rotavirus vaccine; Hep A = hepatitis A.
* Children in the United States Immunization Survey and National Health Interview Survey were aged 24–35 months. Children in the National Immunization Survey were aged 19–35 months.
† Numbers in parentheses refer to the number of doses of that vaccine being tracked in this figure.
§ For rotavirus vaccine, 2 or 3 doses are tracked, depending on the type of rotavirus vaccine received.

Data Source: United States Immunization Survey (1967–1985), National Health Interview Survey (1991–1993), and National Immunization Survey (1994–2012). No data are available for 1986–1990.

Source – Centers for Disease Control and Prevention: Benefits from Immunization During the Vaccines for Children Program Era — United States, 1994–2013

The Share of Large Firms (200 or more Workers) Offering Retiree Health Benefits to Active Workers Has Declined, 1988-2013

Note: Tests found no statistical difference from estimate for the previous year shown (p<.05). No statistical tests are conducted for years to 1999.

Data Sources: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2013; KPMG Survey of Employer-Sponsored Health Benefits, 1991, 1993, 1995, 1998; The Health Insurance Association of America (HIAA), 1988.

Source – Kaiser Family Foundation: Retiree Health Benefits at the Crossroads

Development Assistance for Health for HIV/AIDS; Maternal, Newborn, and Child Health; Malaria; Health Sector Support; Tuberculosis; Non-Communicable Diseases; and Tobacco, 1990–2011

Notes: Health assistance for which we have no health focus area information is designated as “unallocable.” DAH for other health focus areas not yet tracked by IHME is coded as “other.” Due to data limitations, estimates are unavailable for DAH by health focus area for 2012 and 2013.

Data Source: IHME DAH Database 2013

Source – Institute for Health Metrics and Evaluation: Financing Global Health 2013 – Transition in an Age of Austerity

Variation in Coverage Gap between Low-Income and High-Income Children

Notes: * = Ratio is significantly different from one at the 95% level. Analysis by family income is based on the income of the health insurance unit. Estimates with relative standard errors greater than 30% are excluded.

Data Source: 2012 American Community Survey (ACS), as analyzed by SHADAC.

Source – Robert Wood Johnson Foundation: For Kids’ Sake – State-Level Trends in Children’s Health Insurance

Estimated Prevalence* of Autism Spectrum Disorder among Children Aged 8 Years, by Most Recent Intelligence Quotient Score and by Sex and Race/Ethnicity — Autism and Developmental Disabilities Monitoring Network, Seven Sites,† United States, 2010

Notes: IQ = intelligence quotient; * = Per 1,000 children aged 8 years; † = Includes sites that had intellectual ability data available for ≥70% of children who met the ASD case definition.

Source – Centers for Disease Control and Prevention: Prevalence of Autism Spectrum Disorder Among Children Aged 8 Years – Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2010

Uninsurance Rate for Adults Age 18-64 by State Medicaid Expansion Decision

Notes: ‘States expanding Medicaid’ indicates those whose expansion took effect before April 1, 2014. These are regression-adjusted estimates based on models that control for potential differences in the demographic, socioeconomic, and geographic characteristics of the HRMS sample across each quarter. */** = Estimate differs significantly from the quarter 3 2013 uninsurance rate at the 0.05/0.01 levels, using two-tailed tests.

Data Source: Health Reform Monitoring Survey, quarters 1-4 2013 and quarter 1 2014

Source – Urban Institute Health Policy Center: Number of Uninsured Adults Falls by 5.4 Million since 2013

Twenty-Nine Million Insured Paid Premiums in Excess of Affordable Care Act Thresholds, 2011–2012

Note: ‘Affordable Care Act thresholds’ refers to the maximum premium contribution as a share of income in marketplaces or Medicaid if eligible to participate.

Data Source: March 2012–2013 Current Population Survey (states – two-year average)

Source – The Commonwealth Fund: America’s Underinsured – A State-by-State Look at Health Insurance Affordability Prior to the New Coverage Expansions

Rates of Hospitalization for Laboratory-Confirmed Influenza, by Age Group and Surveillance Week — FluSurv-NET,* 2013–14†

* = FluSurv-NET conducts population-based surveillance for laboratory-confirmed influenza-associated hospitalizations in children aged <18 years (since the 2003–04 influenza season) and adults aged ≥18 years (since the 2005–06 influenza season). The FluSurv-NET covers approximately 80 counties in the 10 Emerging Infections Program states (California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New Mexico, New York, Oregon, and Tennessee) and additional Influenza Hospitalization Surveillance Project states (Michigan, Ohio, and Utah).

† = Data reported as of February 14, 2014.

Source: Centers for Disease Control and Prevention: Update: Influenza Activity – United States, September 29, 2013–February 8, 2014

Percentage Medicaid/CHIP, ESI, and Uninsured: Low-Income Children, 1997-2012

Notes: Children are ages 0-18. Low-income is below 200 percent of poverty.

Data Source: ASPE computations from Current Population Survey Annual Social and Economic Supplement (CPS-ASEC) data for Calendar Years 1997-2012 (March 1998 – March 2013 surveys).

Source: US Office of the Assistant Secretary for Planning and Evaluation: Children’s Health Coverage on the 5th Anniversary of CHIPRA

Distribution of Critical Drug Shortages Reported from June 2011 through June 2013, by Route of Administration and Product Type

Notes: This figure reflects 219 of the 382 shortages (57 percent) reported during this time period. Our analysis was limited to the shortages the University of Utah Drug Information Service identified as critical. Red Book is a compendium published by Truven Health Analytics that includes information about the characteristics of drug products.

a = Other drugs includes those that had other routes of administration such as, nasal, inhalation, topical, ophthalmic, and transdermal methods. In total, there were 18 drugs available through other routes, with 4 available in generic form and the remaining 14 only available in brand-name form. The Other drugs category also includes 9 additional shortages that had multiple routes of administration or for which either the route of administration or the product type was unavailable from Red Book.

Data Source: GAO analysis of data from University of Utah Drug Information Service and Truven Health Analytics (Red Book)

Source: U.S. Government Accountability Office: Drug Shortages – Public Health Threat Continues, Despite Efforts to Help Ensure Product Availability

New State Legislative or Regulatory Action on the Market Reforms under the Affordable Care Act, November 2013

Notes: * = States may have decided not to address a particular reform because state law is already consistent with it or because the state has the authority to enforce federal law. For example, Maine, Massachusetts, New Jersey, New York, and Vermont already required insurers to provide coverage to individuals on a guaranteed basis. The exhibit does not take into account such existing laws or authority. ˇ = The state did not pass conforming legislation to implement all or some of the early market reforms but is relying on explicit authority to enforce the early market reforms.

Data Source: Authors’ analysis. For a more detailed description of state implementation of the market reforms, see the Web tools on The Commonwealth Fund’s website.

Source: The Commonwealth Fund: Implementing the Affordable Care Act – The State of the States

Characteristics of People with Difficulty Paying Medical Bills by Health Insurance Type/Status

Data Source: Kaiser Family Foundation analysis of 2012 National Health Interview survey (NHIS) data. Includes all people who reported problems affording medical bills within the past year, and/or gradually paying past bills over time, and/or having medical bills they cannot afford to pay at all.

Source: The Kaiser Family Foundation: Medical Debt among People with Health Insurance

Correctional Per-Inmate Health Care Spending Change by State, 2001 and 2008 (2008 Dollars)

Notes: No data available for states not listed. All spending figures are in 2008 dollars. Nominal fiscal 2001 data provided to Pew by the Bureau of Justice Statistics were converted to 2008 dollars using the Implicit Price Deflator for state and local government consumption expenditures and gross investment included in the Bureau of Economic Analysis’ National Income and Product Accounts.

Data Source: U.S. Department of Justice, Bureau of Justice Statistics

Sources: Pew Charitable Trusts and the John D. and Catherine T. MacArthur Foundation: Managing Prison Health Care Spending

Percentage of People Who Had Selected Experiences with Physician Availability in the Past 12 Months, by Age Group: United States, 2012

Notes: 1 = Significantly different from adults aged 18–64.; 2 = Significantly different from adults aged 65 and over.

Data Source: Data are based on household interviews of a sample of the civilian noninstitutionalized population.

Source: Centers for Disease Control and Prevention: Health Insurance Coverage and Adverse Experiences with Physician Availability: United States, 2012

Uninsured At the Time of Interview—Comparisons of Expanded Regions and National Percentages for Persons under Age 65: United States, January–June 2013

Notes: Expanded regions are based on a subdivision of the four census regions into nine divisions. For this report, the nine census divisions were modified by moving Delaware, the District of Columbia, and Maryland into the Middle Atlantic Division. Estimates for 2013 are based on data collected from January through June. Data are based on household interviews of a sample of the civilian noninstitutionalized population.

Data Source: National Health Interview Survey, 2013, Family Core component.

Source: Centers for Disease Control and Prevention: Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey, January–June 2013

Uninsured Young Adults Targeted by Medicaid and Exchange Subsidies in 2014 Under the ACA

Note: Medicaid eligibility as of January 2014 is modeled in accordance with information released by CMS on September 30, 2013 – CMS Report Available Here

Data Source: Urban Institute analysis of the 2010 Annual Supplement on Economic Conditions to the Current Population Survey.

Source: The Urban Institute: Medicaid and the Young Invincibles Under the Affordable Care Act: Who Knew?

All Health Priorities Seen As Important; Clean Water, Children’s Health, Nutrition Rise To Top

Note: Items asked of half sample. Not at all important (vol.) and Don’t know/Refused answers not shown.

Data Source: Kaiser Family Foundation 2013 Survey of Americans on the U.S. Role in Global Health (conducted August 6-20, 2013).

Source: Kaiser Family Foundation: 2013 Survey of Americans on the U.S. Role in Global Health

Prevalence of Smoking before Pregnancy, during Pregnancy, and after Delivery,* by Year —Pregnancy Risk Assessment Monitoring System, United States, 10 sites,† 2000–2010

Notes: * = Smoking before pregnancy was defined as smoking 3 months before pregnancy on the basis of the PRAMS survey. Smoking during pregnancy was defined as smoking during the last 3 months of pregnancy on the basis of the PRAMS survey. Smoking after delivery was defined as smoking approximately 4 months after delivery on the basis of the PRAMS survey; † = Data aggregated for 10 PRAMS sites (Alaska, Arkansas, Colorado, Hawaii, Maine, Nebraska, Oklahoma, Utah, Washington, and West Virginia) with data available for all years; § = Significant linear trend (p≤0.05).

Source: Centers for Disease Control and Prevention: Trends in Smoking Before, During, and After Pregnancy — Pregnancy Risk Assessment Monitoring System, United States, 40 Sites, 2000–2010

Federal Spending on Major Health Care Programs, by Category, 1973-2023

Data Source: Congressional Budget Office (as of May 2013)

Notes: a) Net Medicare spending (includes offsetting receipts from premium payments by beneficiaries and amounts paid by states from savings on Medicaid’s prescription drug costs); CHIP = Children’s Health Insurance Program.

Source: Congressional Budget Office: Options for Reducing the Deficit: 2014 to 2023

Estimated Number of Children Who Had Not Received 3 Doses of Diphtheria-Tetanus-Pertussis Vaccine (DTP) during the First Year of Life among 10 Countries with the Largest Number of Children Incompletely Vaccinated with DTP, by Country, and Cumulative Percentage of All Incompletely Vaccinated Children — Worldwide, 2012


Source: Centers for Disease Control and Prevention: Global Routine Vaccination Coverage — 2012

Estimated Average Total Health Care Expenditures per Beneficiary by Supplemental Coverage Category and by Part D Enrollment for Medicare FFS-only, 2010

Data Source: GAO analysis of Medicare Current Beneficiary Survey Cost and Use Data, 2010.

Note: This analysis excludes beneficiaries residing in long term care facilities such as nursing homes.

Source: Government Accountability Office: Medicare Supplemental Coverage – Medigap and Other Factors Are Associated with Higher Estimated Health Care Expenditures

Total Medicaid Spending Growth, FY 1996 –FY 2014

Note: Data for State Fiscal Years, for total Medicaid spending, including state, local, and federal funds.

Data Source: For FYs 2000-2011 -Historic Medicaid Growth Rates, KCMU Analysis of CMS Form 64 Data; FYs 2012-2014 -KCMU survey of Medicaid officials in 50 states and DC conducted by Health Management Associates, 2013.

Source: The Henry J. Kaiser Family Foundation: Medicaid in a Historic Time of Transformation: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2013 and 2014

Number of Days of Wage Income Needed by the Lowest-Paid Government Worker to Pay for 30 Days of Drug Treatment for an Adult with Hypertension and a Child with Asthma during the Period 2007-2011

Source: World Health Organization/Health Action International, using data from medicine price and availability surveys undertaken from 2007 to 2011 using the WHO/HAI standard methodology, available from http://www.haiweb.org/medicineprices. Note: OB stands for originator brand and LPG is the lowest-priced generic equivalent. The dosages for hypertension and asthma, respectively, are Captopril 25 mg tab x 2/day and Salbutamol inhaler 100mcg/ dose, 200 doses. Prices for medicines used for these estimates refer to those of private health facilities.

Source: United Nations: The Global Partnership for Development: Making Rhetoric a Reality

Percent of Uninsured Potentially Eligible for the Marketplaces by Second Lowest Cost Silver Premium Relative to ASPE-Derived CBO Estimate, 48 States

Note: This figure uses weighted average second lowest cost silver premiums as depicted in Table 4, before tax credits. States are weighted by the number of uninsured potentially eligible for the Marketplaces.

Source: Office of the Assistant Secretary for Planning and Evaluation: Health Insurance Marketplace Premiums for 2014

Percentage of All Firms Offering Health Benefits, 1999-2013

*=Estimate is statistically different from estimate for the previous year show (p is less than 0.5).

Note: Estimates presented in this exhibit are based on the sample of both firms that completed the entire survey and those that answered just one question about whether they offer health benefits. The percentage of firms offering health benefits is largely driven by small firms. The large increase in 2010 was primarily driven by a 12 percentage point increase in offering among firms with 3 to 9 workers. In 2011, 48% of firms with 3 to 9 employees offer health benefits, a level more consistent with levels from recent years other that 2010. The overall 2011 offer rate is consistent with the long term trend, indicating that the high 2010 offer rate may be an aberration.

Source: The Kaiser Family Foundation and Health Research & Educational Trust: Employer Health Benefit Survey 2013

Percentage of Women Aged 50–64 Years Who Reported Receiving a Mammogram in the Past 2 Years, by Health Insurance Status*† — National Health Interview Survey,§ United States, 1993–2010

Notes: * = Questions concerning mammogram use have differed slightly over the years. Since 2000, respondents were asked for the date of their most recent mammogram; included are women who reported having had a mammogram in the past 2 years. Questions were administered as part of a cancer control supplement conducted in 1993, 1994, 1998, 1999, 2000, 2003, 2005, 2008, and 2010.

† = Health insurance status is coverage at the time of interview. Public insurance includes Medicaid, Medicare, Children’s Health Insurance Program, military, and other public assistance and government programs. Those with only Indian Health Service coverage are classified as uninsured. Because most women aged ≥65 years are covered by public insurance (Medicare), this figure presents data only for women aged 50–64 years.

§ = Data are based on household interviews of a sample of the noninstitutionalized U.S. civilian population.

Source: Centers for Disease Control and Prevention: Selection from the National Health Interview Survey

Increase in Medicaid/CHIP Population (0 to 64) under ACA with All States Expanding Medicaid

Note: See text for details on how geographies are defined and details on data and methods.

Data Source: Urban Institute Analysis, ACS-HIPSM 2012. Estimates derived from 2008, 2009, and 2010 pooled American Community Survey (ACS).

Source: Kaiser Family Foundation: State and Local Coverage Changes under Full Implementation of the Affordable Care Act

Estimated Percentage of Children Enrolled in Kindergarten Who Have Been Exempted from Receiving One or More Vaccines* — United States, 2012–13 School Year

Note: * = Exemptions might not reflect a child’s vaccination status. Children with an exemption who did not receive any vaccines are indistinguishable from those who have an exemption but are up-to-date for one or more vaccines.

Source: Centers for Disease Control and Prevention: Vaccination Coverage Among Children in Kindergarten — United States, 2012–13 School Year

Uninsured Wage and Salary Workers, Ages 18–64, by Reason Not Covered, Dec. 1995–March 2012

Data Source: Employee Benefit Research Institute estimates from the Survey of Income and Program Participation, 1996, 2001, 2004 and 2008 Panels.

Source: Employee Benefit Research Institute: Tracking Health Insurance Coverage by Month: Trends in Employment-Based Coverage Among Workers, and Access to Coverage Among Uninsured Workers, 1995‒2012

Bubble Plot Representing Disability-Adjusted Life Years (DALYs) for EU-25 and Active Ingredients (NCEs)

Note: The areas of the bubbles are DALY’s weighted contribution of each disease condition(s) to the total burden of disease. 1: Other neoplasms; 2: Unintentional injuries (poisoning); 3: Congenital anomalies; 4: Digestive diseases; 5: Respiratory diseases; 6: Skin diseases; 7: Respiratory infections; 8: Maternal conditions; 9: Perinatal conditions.

Source: World Health Organization: Priority Medicines for Europe and the World – 2013 Update

Average Total Maternal Health Care Payments by Payment source among commercial Beneficiaries with Vaginal and Cesarean Births, 2010

Note: Commercial results are weighted to reflect the national employer-sponsored insurance population. Maternal costs include the 9-month prenatal, childbirth, and 3-month postpartum period. Due to rounding, the sum of average payments across payers may not add up to exactly the total average allowed payment.

Source: Truven Health Analytics, with Childbirth Connection, Catalyst for Payment Reform, and the Center for Healthcare Quality and Payment Reform: The Cost of Having a Baby in the United States

Rates of Persons Living with an HIV Diagnosis in the United States, by County

Notes: * Data are not shown to protect privacy. ** State health department requested not to release data. Data include persons with a diagnosis of HIV infection, regardless of the stage of disease at diagnosis, and have been statistically adjusted to account for reporting delays and missing risk-factor information, but not for incomplete reporting.

Data Source: Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division of HIV/AIDS Prevention.

Source: AIDSVu: Illustrating HIV/AIDS in the United States: 2013 Update

ACA Employer Penalty Delayed

The Obama Administration surprised observers last week by announcing a delay from 2014 to 2015 in enforcing a key provision of the Affordable Care Act (ACA) that will penalize businesses (with 50 or more full-time–equivalent employees) for failing to provide affordable health coverage to their employees. To give businesses an incentive to help meet the ACA’s coverage goals, the government will eventually fine businesses that do not offer affordable coverage to their employees or, if they do offer coverage, nevertheless have employees who use federal subsidies to purchase health insurance on the exchanges. The Business Roundtable said this “temporary reprieve” will give businesses “additional time to find workable solutions to these challenges.” Others, however, including the American Hospital Association, found the news “troubling,” especially given uncertainty about Medicaid expansions. ACA opponents responded by airing their broader concerns about the law, whereas ACA proponents stressed the move’s indication that the administration is willing to listen to key constituencies as implementation continues.

Three-Parent IVF

The United Kingdom’s Department of Health and Human Fertilisation and Embryology Authority have approved a controversial technique for in vitro fertilization that would involve combining DNA from three donor parents to create an embryo. IVF physicians would use the technology to prevent mothers from passing on to their children defective genetic material that causes mitochondrial disease. This group of disorders, which can result in heart and liver dysfunction, respiratory problems, and sometimes death, affects 1 in 6500 live births in the UK. The three-parent procedure removes defective DNA from an egg and replaces it with material from a healthy donor egg. That egg is then fertilized, and the resulting offspring is free of mitochondrial disorder. If the UK Parliament votes to enact regulations on this technique later this year, the country would become the first to make this type of genetic manipulation legal.

Repealing and Replacing the SGR

Last week, the House Energy and Commerce Committee unveiled an “advanced legislative framework” to repeal and replace the current sustainable growth rate formula (SGR) that has caused so much angst among physicians who care for Medicare patients. Repealing the controversial SGR, which has dictated annual cuts to physicians’ Medicare fees in order to meet budgetary goals from the Balanced Budget Act of 1997 but has been overridden each year by the unsustainable “doc fix,” is a key element of the draft legislation. The proposal would replace SGR with an “improved” fee-for-service system that relies heavily on provider-developed quality measures. Chairman Fred Upton (R-MI) called the framework a “work in progress” and expressed optimism that the “final product will secure a long-term, fully paid for solution that improves quality of care and, once and for all, removes the gimmicks that have plagued the SGR system.” 

New HIV-Treatment Recommendations

The World Health Organization now recommends beginning antiretroviral therapy (ART) for patients with HIV earlier in the course of infection. The previous recommendations advised starting ART in patients whose CD4 cell count was 350 per cubic millimeter or lower. As HIV infection progresses, the CD4 cell count falls from the normal average of 500 to 1000 per cubic millimeter, indicating a compromised immune system. The new guidelines direct physicians to begin ART for persons with known HIV infection whose CD4 cell counts have dropped below 500 per cubic millimeter. This new standard is based “on evidence that treating people with HIV earlier, with safe, affordable, and easier-to-manage medicines can both keep them healthy and lower the amount of virus in the blood, which reduces the risk of passing it to someone else.” Other new guidelines include providing ART to all HIV-infected children younger than 5, all HIV-infected pregnant or breastfeeding women, and all HIV-positive people with an uninfected partner.

Increasing Painkiller Overdoses

The Centers for Disease Control and Prevention has identified what it calls a growing epidemic of overdoses on prescription painkillers in the United States, primarily among women. The agency released a study last week showing that “although men are still more likely to die of prescription painkiller overdoses (more than 10,000 deaths in 2010), the gap between men and women is closing.” Overdoses of prescription painkillers accounted for the deaths of 6600 U.S. women in 2010, a 400% increase from 1999; there was a 265% increase among men over the same period.  The CDC recommends that physicians recognize that women are at risk for such overdoses, follow guidelines for responsible prescribing, and make use of prescription-drug–monitoring programs.

Texas Abortion Ban Advances

Controversial abortion legislation that would restrict elective abortions after 20 weeks of gestation, impose stricter standards for abortion clinics, and require physicians who perform abortions to have hospital admitting privileges has made its way through the Republican-dominated Texas legislature and attracted the attention of prochoice and prolife advocates nationwide.  Though an 11-hour filibuster last month by State Senator Wendy Davis (D) blocked the Senate version of the legislation (SB-5), the House State Affairs Committee voted 8 to 3 to advance the House version (HB-2) of the proposed abortion ban last week. Governor Rick Perry (R), who supports the ban and called for a second special legislative session on July 1 so the legislature could do “history-making work,” predicted on Sunday that the measure would pass.

Not Medicaid-Eligible? Individual Mandate May Not Apply

In its final rule specifying exemptions from the Affordable Care Act’s “shared responsibility payment,” the Department of Health and Human Services essentially waives the individual mandate for persons who are deemed ineligible for Medicaid solely because their state has opted not to expand its Medicaid program.  In other words, in states that elect not to extend the Medicaid eligibility threshold to 138% of the federal poverty level, persons who would have been newly eligible for Medicaid under such an extension will not be assessed a penalty for going without insurance coverage. The new health insurance exchanges will be responsible for granting certificates to persons (including members of this new group) who meet exemption requirements when this provision goes into effect in January 2014. This announcement coincided with a new Gallup poll showing that only 43% of uninsured Americans are aware of the individual mandate.

FDA Takes Action on New Tobacco Products

The FDA has made its first decisions on new tobacco products submitted for marketing approval through its “substantial equivalence” pathway.  The Family Smoking Prevention and Tobacco Control Act of 2009 granted the FDA, through its Center for Tobacco Products, the power to “regulate the manufacture, distribution, and marketing of tobacco products to protect public health,” and the agency has now exercised that power for the first time, by approving two new products — Newport Non-Menthol Gold Box 100s and Newport Non-Menthol Gold Box — and denying approval to four others. The FDA concluded that though the two approved products “have different characteristics than the predicate products, the new products do not raise different questions of public health.” The agency said it could not declare the four other products substantially equivalent to existing tobacco products because it lacked details about their designs and had insufficient evidence of their safety.

Percentage of Companies Offering a Particular Wellness Program To Their Employees, by Firm Size, 2012

Notes: “Small firms” are those with 3-199 workers; “large firms” are those with 200 or more workers.

Data Source: Kaiser Family Foundation and Health Research and Educational Trust, “Employer Health Benefits: 2012 Annual Survey,” September 11, 2012.

Source: Health Affairs: Health Policy Brief: Workplace Wellness Programs

Reducing Fat and Sugar in U.S. Schools

The new “Smart Snacks in School” nutrition standards, released by the U.S. Department of Agriculture on June 28, will markedly reduce the availability of junk foods at schools throughout the country. Starting in July 2014, all “competitive foods and beverages” made available to schools participating in the National School Lunch and School Breakfast Program will be required to meet the new nutrition rules, which range from a prohibition on trans fats to the curtailing of high-calorie and sugar-dense products. Public health agencies praised the new guidelines called for by the Hunger-Free Kids Act of 2010. Risa Lavizzo-Mourey, CEO of the Robert Wood Johnson Foundation, stated that “Together with recent efforts to improve school meals, these updates will help to create a culture of health in schools and a better future for millions of children.”

Updated Hepatitis C Screening Recommendations

In addition to screening in adults who are at high risk for hepatatis C infection, such as people with current or past injection-drug use and people who received a blood transfusion before 1992, the U.S. Preventive Services Task Force now recommends one-time screening for anyone born between 1945 and 1965.  The cochair of the USPSTF, Albert Siu, notes that three out of four people with hepatitis C infection were born during that period.  The new guidelines are meant to ensure that infected adults 48 to 68 years of age who are unaware of their infection receive a diagnosis and, if necessary, treatment.

Medication Nonadherence in the United States

Nonadherence to medications by Americans with chronic conditions threatens patients’ health and can “add vast costs to the health care system — an estimated $290 billion annually,” according to the National Community Pharmacists Association, which recently released an adherence “report card.”  The patients surveyed by the NCPA received a C+, on average, for overall adherence.  The survey queried patients about several nonadherence behaviors, including failing to fill or refill a prescription, skipping doses of medication, and stopping a prescribed course of medication early. The results were then scored according to how many nonadherence behaviors patients admitted to, with 0 indicating admission of all behaviors and 100 indicating admission of none. The report also examines possible reasons for nonadherence, such as the cost of prescription medications and patients’ feeling uninformed about their conditions.

Illegal Pharmacy Websites Shut Down

As part of “Operation Pangea VI,” the U.S. Food and Drug Administration — in collaboration with international regulatory and law-enforcement agencies — took action last week against more than 9600 illegal pharmacy websites in an effort to protect consumers from counterfeit, unapproved, and potentially dangerous prescription medicines.  A total of 1677 websites were shut down, and more than $41 million worth of illegal medicines were seized worldwide.  The websites, including some that purported to be sites of well-known pharmacies such as Walgreens and CVS, now display a banner of the FDA cybercrime unit.  The director of the FDA’s Office of Criminal Investigations, John Roth, remarked that “illegal online pharmacies put American consumers’ health at risk by selling potentially dangerous products. This is an ongoing battle in the United States and abroad, and the FDA will continue its criminal law enforcement and regulatory efforts.”

Pay-for-Delay Agreements Subject to Antitrust Law

In a 5-to-3 decision, the U.S. Supreme Court ruled on June 17 that “pay-for-delay agreements” between brand-name and generic pharmaceutical companies are “not immune to antitrust attack.” The case — Federal Trade Commission v. Actavis — centered on the product AndroGel, which was first manufactured by Solvay Pharmaceuticals in 2000. Although Actavis had created a generic version of the testosterone gel, it entered into a “reverse payment” agreement with Solvay, agreeing not to bring its product to market for 9 years in exchange for $19 million to $30 million annually. Previous courts had held that such agreements fell within the “scope of patent,” but the Supreme Court’s ruling reverses these earlier decisions, noting that such pay-for-delay settlements could have “significant adverse effects on competition.”  The FTC claimed that the ruling was a “significant victory for American consumers,” estimating that current pay-for-delay agreements throughout the industry “cost Americans $3.5 billion a year in higher drug prices.”

HPV Vaccine Proves Effective

The human papillomavirus (HPV) vaccine has helped to reduce the rate of HPV infections among teenage girls, according to a new study from the Centers for Disease Control and Prevention. Data from the CDC’s annual National Health and Nutrition Examination Survey revealed that the prevalence of vaccine-type HPV prevalence among U.S. girls 14 to 19 years of age has dropped by 56% since the vaccine was introduced in 2006.  Lauri Markowitz, who led the study, says that the decrease “is higher than expected and could be due to factors such as to herd immunity, high effectiveness with less than a complete three-dose series and/or changes in sexual behavior we could not measure.” CDC Director Tom Frieden also notes that, although the findings are encouraging, “only one third of girls aged 13-17 have been fully vaccinated with HPV vaccine” in the United States; the agency hopes to increase the rate to 80% in coming years.

Health Insurance Exchange Arrangements for 2014 as of May 10, 2013

Notes: A) Iowa planned to assist with the plan management function, and not the consumer assistance function. B) On May 10, 2013, CMS indicated that it intended that Utah would operate a state-based Small Business Health Options Program (SHOP) exchange, but the individual exchange would be an FFE, for which Utah would assist with plan management.

Data Source: GAO analysis of CMS information

Source: Government Accountability Office: Status of CMS Efforts to Establish Federally Facilitated Health Insurance Exchanges

Morning-After Pill Approved for Over-the-Counter Sale

In compliance with a recent federal court ruling, the Food and Drug Administration has now approved Plan B One-Step (levonorgestrel) — commonly referred to as the “morning-after pill” —  to be sold over the counter without any age restrictions. The emergency contraceptive had been the subject of great debate, especially since the Department of Health and Human Services determined that, because of concern about misuse or inability to comprehend the label, the one-pill contraceptive should continue to be available only by prescription to girls younger than 17. Teva Pharmaceuticals, the product’s manufacturer, praised the FDA’s decision, stating that bringing this drug “out from behind the pharmacy counter helps women tremendously by removing one of the biggest barriers to access and timely use of emergency contraception, which is critically important.”

NIH Explores New Uses for Old Drugs

The National Institutes of Health has awarded a total of $12.7 million as part of a program called Discovering New Therapeutic Uses for Existing Molecules. The program, which aims to promote study of new uses for “abandoned” drugs, is an initiative of the NIH’s National Center for Advancing Translational Sciences, a 19-month-old center whose goal is to accelerate drug development.  One year ago, eight pharmaceutical companies (AbbVie [previously Abbott], AstraZeneca, Bristol-Myers Squibb, Eli Lilly, GlaxoSmithKline, Janssen Research & Development, Pfizer, and Sanofi) donated a total of 58 compounds to the program and shared their data about them.  Academic research teams then submitted proposals for testing one of these compounds for “its effectiveness against a previously unexplored disease or condition.”  Nine research teams’ proposals exploring eight disease areas — alcohol dependence, Alzheimer’s disease, calcific aortic valve stenosis, nicotine dependence, peripheral artery disease, schizophrenia, Duchenne’s muscular dystrophy, and lymphangioleiomypmatosis (a progressive lung disease) — have been accepted and funded by the NIH.

“America’s Essential Hospitals”

On June 20, the National Association of Public Hospitals, an advocacy organization for safety-net hospitals, launched its new brand and name: America’s Essential Hospitals.  Growth of the organization, which started in 1981 with 5 public hospitals and has increased to a membership of more than 200, prompted NAPH to review its brand in the spring of 2012.  The outcome, which was approved last month, signifies that the diverse membership of public and not-for-profit hospitals are “united by a mission to ensure access to the best care possible for all patients, including those with no ability to pay.” Moreover, the organization claims that the new brand “preserves the sense of public accountability central to its legacy and celebrates the mission of its members to ensure access to quality care for those in greatest need.”

AMA Declares Obesity a Disease

At its Annual Delegate Meeting last week, the American Medical Association voted to recognize obesity as a disease. This decision comes shortly after the association’s own Council on Science and Public Health released a report to the delegates concluding that “it was premature to classify obesity as a disease.” The council cited “the lack of characteristic signs or symptoms due to obesity, as well as evidence of any true causal relationships between obesity and morbidity and/or mortality” as reasons for not defining obesity as a disease in the classic sense. Although they took the council’s report under advisement, the AMA delegates believed that its “reasons did not justify rejection of the notion of obesity as a disease.”  The AMA hopes that classifying obesity as a disease will help to change the way the medical community approaches interventions for the condition and other diseases, such as diabetes and cardiovascular disease, that are associated with it.

Number and Percentage of Respiratory Specimens Testing Positive for Influenza Reported to CDC, by Type and Surveillance Week and Year — World Health Organization and National Respiratory and Enteric Virus Surveillance System Collaborating Laboratories, United States, September 30, 2012–May 18, 2013


Source: Centers for Disease Control and Prevention: Influenza Activity — United States, 2012–13 Season and Composition of the 2013–14 Influenza Vaccine

Percentage of Persons under Age 65 in Families Having Problems Paying Medical Bills in the Past 12 Months, by Poverty Status and 6-Month Interval: United States, January 2011–June 2012

Notes: 1: Significantly different from not poor (p < 0.05), 2: Significantly different from near poor (p < 0.05), 3: Significant linear decrease from January–June 2011 to January–June 2012 (p < 0.05).
Data are based on household interviews of a sample of the civilian noninstitutionalized population.

Source: National Center for Health Statistics: Problems Paying Medical Bills: Early Release of Estimates From the National Health Interview Survey, January 2011–June 2012

Human Genes Ruled Not Patentable

On June 13, the U.S. Supreme Court unanimously ruled that isolated, naturally occurring human DNA cannot be patented.  In the same opinion (Association for Molecular Pathology v. Myriad Genetics, Inc.), it held that a type of synthetic DNA known as complementary DNA is patent-eligible since it is not “a product of nature.”  At the center of the case was the work of Myriad Genetics, the biotech firm that isolated and sought patent protection for BRCA1 and BRCA2, gene mutations linked to increased risk for breast and ovarian cancer.  Francis Collins, director of the National Institutes of Health, praised the decision, noting that it “represents a victory for all those eagerly awaiting more individualized, gene-based approaches to medical care” and that “the right to control exclusively the use of a patient’s genes could have made it more difficult to access new tests and treatments that rely on novel technologies that can quickly determine the sequence of any of the estimated 20,000 genes in the human genome.”

Walgreens to Pay $80 Million in DEA Fines

Walgreens Corporation , the country’s largest drug-store chain, has agreed to pay $80 million in fines for violations of the Controlled Substances Act — the largest settlement in the history of the Drug Enforcement Agency. Walgreens had been investigated by the DEA and the U.S. Attorney’s Office regarding allegations of negligence in the handling and distribution of prescription painkillers after several drug shipments were “diverted for abuse and illegal black market sales.” The investigation largely focused on a distribution center in Jupiter, Florida, and six retail pharmacies in that state but also included outlets in Colorado, Michigan, and New York State. Kermit Crawford, Walgreens’ president of pharmacy, health, and wellness, indicated that the company is “fully committed to doing our part to prevent prescription drug abuse” and will work with community leaders, physicians, pharmacists, drug distributors, and regulators to meet that goal.

Medicare Advantage Enrollment Hits Record High

Unexpectedly, enrollment in the Medicare Advantage (MA) program has continued to increase over the past year, according to a new report from the Kaiser Family Foundation and Mathematica Policy Research. Nearly 28% of Medicare beneficiaries (14.4 million people) are now enrolled in these private insurance plans that contract with Medicare to provide benefits to seniors. Though projections suggested that the Affordable Care Act’s payment changes for MA would lead to reduced enrollment, the number of MA beneficiaries has increased by more than 30% since the law passed in 2010, with approximately 1 million new people opting for MA plans over the past year.  Though total enrollment has increased, there is wide variation among states in the share of Medicare beneficiaries in MA plans — from 49% in Minnesota to less than 1% in Alaska.

Updated CDC Guidelines on HIV Prophylaxis

The Centers for Disease Control and Prevention has updated its guidelines for preexposure prophylaxis (PrEP) for the prevention of HIV infection in injection-drug users.  The update stems from the positive results of a recent randomized clinical trial sponsored by the CDC and the Thailand Ministry of Health, which demonstrated the preventive efficacy of a daily dose of 300 mg of tenofovir disoproxil fumarate (TDF) given to HIV-negative injection-drug users.  The CDC now recommends that PrEP with an antiretroviral drug such as TDF “be considered as one of several prevention options for persons at very high risk for HIV acquisition through the injection of illicit drugs.” Later this year, the CDC plans to release comprehensive guidelines on the use of PrEP in men who have sex with men, heterosexually active men and women, and injection-drug users.

AMA Awards Grants to 11 Medical Schools

Eleven medical schools will receive $1 million grants from the American Medical Association as part of its “Accelerating Change in Medical Education” initiative.  The AMA announced the grant program in January, asking medical schools to submit proposals for altering undergraduate medical education “through bold, rigorously evaluated innovations” in order to prepare medical students to meet the future needs of the U.S. health care system.  The 11 schools’ grant projects include a plan at Brown University’s Warren Alpert Medical School to offer a dual M.D.-M.S. degree in primary care and population health and a plan of the Mayo Medical School to offer a curriculum in the “science of healthcare delivery” that will “prepare students to practice within patient-centered, community-oriented, science-driven collaborative care teams.”

Arizona Approves Medicaid Expansion

On Monday, Arizona Governor Jan Brewer (R) signed a law permitting the Medicaid-expansion provision of the Affordable Care Act to be implemented in her state — a move that’s expected to benefit nearly 300,000 Arizonans. The political battle between Arizona’s Republican-dominated legislature and the state executive has been the subject of intense media coverage since Brewer surprised pundits by announcing her support for the expansion in January. In her statement, she noted the political risks involved in the decision and the expected benefits, stating that “this Medicaid Restoration Plan does not solve all of Arizona’s health care challenges. But it will extend cost-effective care to Arizona’s working poor, using the very tax dollars our citizens already pay to the federal government. It will help prevent our rural and safety-net net hospitals from closing their doors.” Opponents of the decision are considering options for a ballot referendum in 2014.

Pediatric Lung-Transplant Controversy

The Organ Procurement and Transplantation Network (OPTN) made headlines over the past week as legislators, high-level officials, courts, and a media campaign weighed in on the cases of Sarah Murnaghan and Javier Acosta — children younger than 12 who have end-stage cystic fibrosis and need lung transplants. The debate concerns OPTN’s “Under 12” rule (Policy 3.7), which delineates a separate process for allocating lungs to transplantation candidates who are 0 to 11 years of age, first prioritizing children for a limited pool of lungs from child donors (as versus the somewhat-more-available adult lungs). A federal court ruling called the rule “arbitrary, capricious, and an abuse of discretion” and allowed Murnaghan and Acosta to be placed on the waiting list for adult lung transplants and treated similarly to older candidates. On June 10, OPTN convened an emergency executive session and ordered a review of the Under 12 rule; in the interim, it will allow sick children in need of lungs to have their cases reviewed by an expert panel.

Unrestricted OTC Sales of Emergency Contraceptive

In the wake of the FDA’s decision to approve the emergency contraceptive Plan B One-Step for all girls and women 15 years of age or older, the Obama administration announced in a letter to Judge Edward R. Korman on June 10 that it would comply with Korman’s ruling that the drug should be made available over the counter without any age or point-of-sale restrictions.  The unrestricted sale of the contraceptive will not begin immediately, since the manufacturer, Teva, must first submit a supplemental new drug application to the FDA with proposed new labeling — an application that the FDA, however, says it will approve “without delay.” The lifting of the restrictions on Plan B One-Step will not extend to the two-dose version of the drug, Plan B, or its generic equivalents.

Confirmed Measles Cases* by Month of Rash Onset — World Health Organization Western Pacific Region (WPR), 2009–2012

Abbreviation: SIA = supplementary immunization activity.

* Confirmed measles cases reported by countries and areas to World Health Organization. A case of measles is confirmed by serology when measles-specific immunoglobulin M antibody is detected in a person who was not vaccinated in the previous 30 days. A case of measles is confirmed by epidemiologic linkage when linked in time and place to a laboratory-confirmed measles case but lacks serologic confirmation. During 2009–2012, a case of measles meeting the case definition but without a specimen collected could be reported as clinically confirmed.

† SIA conducted in China in which approximately 100 million children aged 8–179 months were vaccinated against measles, with targeted age group varying by province.

Source: Centers for Disease Control and Prevention: Progress Toward Measles Elimination — Western Pacific Region, 2009–2012

Consumer Cost Savings from Medical Loss Ratio

In 2012, the Medical Loss Ratio (MLR) provision of the Affordable Care Act saved consumers approximately $2.1 billion, mostly in the form of reduced premiums, according to the Kaiser Family Foundation. The provision requires insurers to spend a certain percentage of their enrollees’ premiums on health care services and quality-improvement efforts, thereby limiting the portion that can be retained in profits or spent on administration and marketing. Insurers who do not meet the benchmarks must issue rebates to their enrollees; such rebates amounted to an estimated $1.1 billion last year.  Since the majority of savings are thought to be from premium reductions rather than rebates, however, the report noted: “Perhaps ironically, when the MLR provision is working as intended and insurers set premiums to meet the thresholds, consumers save money but are less likely to get a check in the mail as tangible demonstration of those savings.”

Global Sharing of Genomic Data

The Eli and Edythe L. Broad Institute of Harvard and MIT, a collaborative biomedical research institution— along with more than 50 other U.S. and global health care, research, and advocacy organizations — has released a plan to compile and enable the secure sharing of genomic and clinical data. All participating organizations have signed a nonbinding letter of intent in which they pledge to “work together to create a not-for-profit, inclusive, public-private, international, non-governmental organization (modeled on the World Wide Web Consortium, W3C).”  The organization and its participating members will not only bring together a large evidence base for new research in genomics and other biomedical fields, but will also ensure that the data are shared with investigators in effective and ethical ways. Broad and its partners are seeking additional signatories to build this worldwide research alliance.

Loosening Rosiglitazone Restrictions?

A joint advisory committee to the Food and Drug Administration has recommended that the agency ease restrictions on the diabetes drug rosiglitazone (Avandia). Sales of the former blockbuster drug began to markedly decline in 2007 after safety concerns were widely publicized. The FDA pulled rosiglitazone from pharmacy shelves in 2010, after data suggested that patients who took it had elevated cardiovascular risk. Even if marketing restrictions are lifted, prospects for widespread prescribing may be dim, since only 3400 people in the United States reportedly still take rosiglitazone (now available only through a special registry) and its patent expired in 2011. The drug’s manufacturer, GlaxoSmithKline, says that it continues “to believe that Avandia is a safe and effective treatment option for type 2 diabetes when used for the appropriate patient and in accordance with labeling” and that it will work with the FDA as its considers the committee’s recommendation.

Federal Focus on Mental Illness

On June 3, the White House hosted the National Conference on Mental Health, a day-long meeting involving health care experts, psychologists, faith leaders, veterans’ advocates, and administration officials. The administration hopes that the conference will “kick off a national conversation about mental health in the United States.” The conference was meant to be a brainstorming session about possible ways to reduce the social and medical stigmas related to mental illness as well as approaches to educating people with mental illnesses about reaching out for assistance.  In tandem with the conference, the administration launched a website, MentalHealth.gov, whose aim is “providing resources for those suffering from mental illness and sharing success stories from those who’ve received treatment.”

Access to Care Worsening in U.S.

Although the quality of U.S. health care is improving, it is still “suboptimal,” access to care is worsening, and health care disparities are not narrowing, according to the annual National Healthcare Quality Report released at the end of May by the Agency for Healthcare Research and Quality.  On average, says the AHRQ, 26% of Americans reported that they faced barriers to obtaining health care in 2009; those who did have access received an average of only 70% of indicated health care services.  Black and Hispanic Americans received worse care than non-Hispanic whites; and there were continued large disparities in care according to patients’ income level. The report highlights some specific areas requiring “urgent attention”: the quality of diabetes care and maternal and child health care; disparities in cancer care; and the quality of care in Southern states.

Solvency of Medicare Trust Fund Extended

In its 2013 annual report, Medicare’s board of trustees indicates that Medicare’s hospital insurance (Part A) trust fund will remain solvent until 2026. As of last year’s annual report, the trust fund was expected to be exhausted 2 years earlier. The new projections are based on current law, including the implementation of cuts to physician payments dictated by the sustainable growth rate formula and the approximately 165 provisions of the Affordable Care Act related to the financing and delivery of Medicare services. The updated projection should therefore not be read as the trustees’ “most likely expectations of actual Medicare financial operations,” notes the board, but rather as “illustrations of the very favorable impact of permanently slower growth in health care costs.”  The report calls for “timely and effective action” to resolve the financial challenges plaguing Medicare, which currently has more than 50 million enrollees and spent more than $574 billion in 2012.

Limited Uptake of Workplace Wellness Programs

About half of U.S. employers now offer employee wellness programs, which usually include both health-risk screening (often through self-administered questionnaires) and preventive interventions, according to a new survey conducted by RAND. The interventions generally focus on nutrition, weight-related activities, and smoking cessation, though some also address alcohol and drug abuse or stress management.  Among participating employees, the researchers found sustained, “clinically meaningful improvements in exercise frequency, smoking behavior, and weight control, but not cholesterol control.” But less than half of employees participate in screenings, and one fifth or less of those offered lifestyle interventions take their employers up on the offer. Employers providing such programs believe they reduce “medical cost, absenteeism, and health-related productivity losses,” but most are not formally evaluating the effects.

Rule on Workplace Wellness Programs Finalized

Last week, the Obama administration released its final rule for workplace wellness programs. Updating the relevant 2006 regulations, the rule enhances employers’ ability to provide incentives to their employees for engaging in healthy behavior. Wellness
programs can be either participatory — providing no reward for performance (for example, an offer of a free gym membership) — or health-contingent — rewarding
employees with reductions in the cost of their health insurance premiums for completing
an activity such as participation in a walking program or achieving a particular health outcome, such as quitting smoking.  Concurrent with the rule’s release, RAND
issued a report on the current state of wellness programs, stating that approximately half of all employers with more than 50 employees offer some type of wellness program, which “can help contain the current epidemic of lifestyle-related diseases.”

WHO Calls for Banning Tobacco Advertising

In honor of World No Tobacco Day on Friday, May 31, the World Health Organization issued a call for countries to prohibit all tobacco advertising, promotion, and sponsorship. Countries that have implemented such bans, says the WHO, have reduced tobacco consumption by an average of  7%, and the effect may be larger on young people who have not yet started smoking.  Yet more than a third of countries have minimal or no restrictions on these activities.  The countries that have gone the farthest in prohibiting tobacco advertising, according to the WHO, are Albania, Brazil, Colombia, Ghana, Iran, Mauritius, Panama, and Vietnam. The U.S. CDC, for its part, celebrated World No Tobacco Day by reporting that the use of antismoking ads was effective in 14 of 17 countries in encouraging smokers to attempt to quit.

Immigration and Health Care

On May 21, the Senate Judiciary Committee passed a bill (S.744) that would provide a
pathway for citizenship for 11 million undocumented immigrants. It is expected to come before the full Senate next week. Before the committee’s action, the possibility of expanding the benefits of health care reform to undocumented immigrants had been taken off the table as part of a bipartisan effort to keep immigration reform alive. At the same time, House Republicans are tinkering with legislation that would require undocumented immigrants to obtain health insurance before gaining full citizenship status. Some observers have noted the political complications faced by such a move, drawing parallels between the proposal and the ACA’s individual mandate to obtain insurance coverage, which the GOP-led House has strongly opposed and voted to repeal yet again on May 16.  Meanwhile, a new report reveals that between 2002 and
2009, immigrants paid $115 billion more into Medicare than the program paid for
their medical expenses.

Projected Medicaid and Medicare Spending Has Fallen by $900 Billion Since August 2010

FY = Fiscal Year. Congressional Budget Office baseline projections of Medicaid spending excluding spending related to the Medicaid expansion under the Affordable Care Act. CBO baseline projections of Medicare spending net of premiums, without sustainable growth rate (SGR) cuts or sequestration. May 2013 projections include actual spending for FY2010-12.

Data Source: CBPP analysis based on Congressional Budget Office estimates.

Source: Center on Budget and Policy Priorities: Projected Medicare and Medicaid Spending Has Fallen by $900 Billion

CDC Report on Children’s Mental Health

On May 17, the Centers for Disease Control and Prevention released a report focusing on childhood mental disorders and mental health surveillance methods currently in use in the United States. Noting that mental disorders’ prevalence (13 to 20% overall), early onset, and effects on children, their families, and their communities make these conditions a key public health issue (costing $247 billion annually), the report describes federal surveillance systems such as the National Survey of Children’s Health and other methods of measuring the incidence and indicators of mental disroders.  Aggregating the surveillance systems’ findings, the CDC lists the prevalence of the most common mental disorders found in children, which include attention-deficit–hyperactivity disorder (6.8%), behavioral or conduct problems (3.5%), anxiety (3.0%), depression (2.1%), and the autism spectrum disorders (1.1%).  The CDC says it hopes to “develop better ways to document how many children have mental disorders, better understand the impacts of mental disorders, inform needs for treatment and intervention strategies, and promote the mental health of children.”

Contraceptive-Coverage Mandate Reaches Appeals Courts

Last week, a number of appellate courts, including the 7th Circuit Court of Appeals, heard oral arguments related to the Affordable Care Act (ACA) provision requiring employers to cover (without cost sharing) certain preventive care, including FDA-approved contraceptive methods. Some nonprofit religious groups were afforded an exemption last year from fulfilling these requirements by the August 2012 deadline. Now, some for-profit employers, including the Oklahoma-based crafts-store chain Hobby Lobby and Grote Industries of Indiana, are seeking a similar exemption from the contraception-coverage mandate, contending that it conflicts with their religious beliefs. Many observers expect that one of the approximately 59 challenges to this mandate, which assert that it violates a variety of constitutional rights as well as the Religious Freedom Restoration Act, will eventually make its way to the Supreme Court.

Still Fighting the Contraceptive-Coverage Mandate

A prominent case involving an employer’s refusal to cover birth control (without cost sharing)  in its employee health insurance plans, as required by the contraceptive mandate contained in the Affordable Care Act, has moved into the U.S. Court of Appeals for the 10th Circuit (in Denver). In November 2012, Hobby Lobby Stores v. Sebelius came before a U.S. District Court in Oklahoma, which denied the company’s motion for a preliminary injunction prohibiting the federal government from enforcing the mandate against it.  The complainant, a chain of arts and crafts retailers based in Oklahoma City, is one of many companies claiming that the requirement violates their rights under the Religious Freedom Restoration Act of 1993.  Oral arguments in the appeal case began on May 23.

Glycated Hemoglobin Test Approved for Diagnosing Diabetes

As of May 23, health care professionals can use the Cobas Integra 800 Tina-quant HbA1cDx assay (Roche) to diagnose diabetes, which affects an estimated 25.8 million people in the United States. Although other glycated hemoglobin tests have been on the market for monitoring blood glucose and have been used unofficially for diabetes diagnosis, this is the first product to receive FDA approval to be marketed for the purpose of diagnosing the disease. Alberto Gutierrez of the FDA’s Center for Devices and Radiological Health remarked that “providing health care professionals with another tool to identify undiagnosed cases of diabetes should help them provide patients appropriate guidance on treatment before problems develop.”

Covered California Announces Insurers, Proposed Rates

As states continued to prepare for the January 1, 2014, deadline for launching their health insurance exchanges, California, the country’s most populous state, announced last week which insurers would be participating in its exchange and the expected premiums for individuals enrolling in their plans. Nearly three dozen insurers submitted bids to provide health coverage through Covered California — the state’s exchange that will operate as a one-stop shop for the 5.3 million Californians expected to receive federal subsidies to purchase health insurance — and 13 were selected.  Exchange leaders touted the rates proposed for the individual market as a “home run for consumers in every region of California.”  Consumers Union (the policy and action division of Consumer Reports) praised the exchange’s move, stating that its publicizing of this information “will make it dramatically easier for consumers to compare plans and make smart choices that fit their budget.”

Global Health Funding up 1.6% in U.S. FY2014 Budget

U.S. funding for global health programs under the Global Health Initiative would be increased to an estimated $9.0 billion in fiscal year 2014 (from $8.9 billion in fiscal years 2012 and 2013) under President Obama’s proposed budget, according to a Kaiser Family Foundation analysis. More than half of the total (54%, or $4.9 billion) is directed to funding PEPFAR’s work in HIV–AIDS; $4.0 billion would go to the State Department, $399 million to the National Institutes of Health, $330 million to the U.S. Agency for International Development, and $132 million to the Centers for Disease Control and Prevention.  The budget request also calls for $1.65 billion to be contributed to the Global Fund to Fight AIDS, Tuberculosis, and Malaria — a 27% increase from fiscal years 2012 and 2013.

Percentage of Firms Offering Family Coverage That Enrolled Adult Dependents up to Age 26 as a Result of PPACA,* and Average Number of Adult Dependents Enrolled, by Firm Size, 2012

Data Sources: http://ehbs.kff.org/?page=charts&id=1&sn=29&ch=2828 and http://ehbs.kff.org/?page=charts&id=1&sn=29&ch=2829

*Patient Protection and Affordable Care Act

Source: Employee Benefit Research Institute: Mental Health, Substance Abuse, and Pregnancy: Health Spending Following the PPACA Adult-Dependent Mandate

Tavenner Confirmed as CMS Administrator

On Wednesday, May 15, on 91-to-7 vote, Marilyn Tavenner became the first Senate-confirmed administrator of the Centers for Medicare and Medicaid Services since 2006. Tavenner has been serving as acting administrator of the $800 billion agency since December 2011, when her predecessor, Don Berwick, resigned after it became clear that Senate confirmation was politically infeasible. Though Tavenner enjoyed a rare level of bipartisan support throughout the nomination process, her confirmation was unexpectedly delayed by Senator Tom Harkin (D-IA) because of his concerns about the redirection of funding from prevention efforts to implementation of health care reform. The American Medical Association was among the many groups that applauded Tavenner’s confirmation, expressing its intent to “work with the administrator to strengthen the Medicare system to improve health outcomes for patients and the practice environment for physicians.”

Discount on HPV Vaccines in Low-Income Countries

The Global Alliance for Vaccination and Immunisation (GAVI) has reached a deal with the pharmaceutical companies Merck and GlaxoSmithKline to reduce the price per dose of two brands of human papillomavirus (HPV) vaccine for several low-income countries. For a 4-year period beginning this year, Merck will make its Gardasil vaccine available for $4.50 per dose and GlaxoSmithKline will charge $4.60 per dose for its Cervarix vaccine. These vaccines typically cost more than $100 per dose in high-income countries, and three doses must be administered over a 6-month period. GAVI intends to begin immunization programs with the reduced-price vaccines as early as the end of May in eight countries: Kenya, Ghana, Lao PDR (Laos), Madagascar, Malawi, Niger, Sierra Leone, and the United Republic of Tanzania. By 2020, GAVI hopes to have vaccinated “more than 30 million girls in more than 40 countries.”

Vermont Passes Physician-Assisted–Suicide Bill

On May 20, Vermont Governor Peter Shumlin signed into law An Act Relating to Patient Choice and Control at the End of Life, which had been passed by the Vermont House of Representatives and Senate over the previous two weeks. The law allows physicians to prescribe lethal medication to terminally ill, mentally competent patients who want to end their lives. With its passage, Vermont becomes the first state to approve a “death with dignity” law through legislation: Oregon and Washington State enacted their similar laws through public referenda. The Vermont law mandates adherence to certain protocols in order to protect terminally ill patients from coercion or changes of heart. Physicians prescribing lethal medications for terminally ill patients according to the rules set forth in the law will be protected from civil and criminal liability and from charges of professional misconduct.

House Repeals the ACA (Again)

The 37th attempt to repeal the Affordable Care Act (in part or in whole) was passed by the House of Representatives on May 16.  The bill (H.R. 45) passed on a 229–195 party-line vote, with only two Democrats, both of whom had supported previous repeal bills, voting with Republicans to repeal. Although the legislation is expected to fail in the Democratic-led Senate (and would be vetoed by President Obama), it has added to the political complexities surrounding the ACA during a critical time in its implementation. The bill’s sponsor, Representative Michelle Bachmann (R-MN), was among the ACA critics who linked the timing of the vote with the current controversy surrounding the Internal Revenue Service, which is responsible for enforcing key ACA features related to the individual mandate.

New IOM Report on Salt Intake

A report released on May 14 by the Institute of Medicine focuses on the current body of research related to dietary sodium consumption and health outcomes in various U.S. populations, including those with hypertension, pre-hypertension, and diabetes, as well as black Americans and those 51 years of age or older.  Although the report confirms that there is a positive correlation between high levels of sodium intake and risk of cardiovascular disease, it also notes that the most recent studies lack a consistent methodology and highlights limitations in both the quality of measures of sodium intake and the “quantity of available evidence assessing sodium intake and health outcomes.”  The IOM also reports that some new studies suggest that very low sodium intake may increase the risk of adverse health effects in patients with moderate-to-severe cardiovascular disease who are receiving some aggressive forms of treatment.

New Proposed Rule for DSH Payments

The Centers for Medicare and Medicaid Services released a proposed rule to delay an expected $500 million cut in payments to hospitals that see a disproportionate share of low-income patients — cuts that were to go into effect in 2014 under the Affordable Care Act. The logic behind the cuts was that Disproportionate Share Hospital (DSH) payments (which amounted to about $11 billion in 2011) could be reduced over time as the number of uninsured patients decreased thanks to expanding coverage. Given the Supreme Court ruling on the ACA and subsequent uncertainty about which states will expand Medicaid, the proposed rule notes CMS’s intent “to account for the different circumstances among states” when calculating DSH cuts in the future. The American Hospital Association responded to the proposed rule stating that “it will not discourage [Medicaid] expansion, nor will it penalize hospitals in those states that have yet to make a decision.”

Hospital Charges Vary Widely

As the debate over price transparency in health care continues, the Obama administration released data showing “significant variation across the country and within communities in what hospitals charge for common inpatient services.”  This action is part of an initiative announced by the Department of Health and Human Services on May 8, which aims to inform consumers about what hospitals charge for routine services and also provides $87 million in funding for states to enhance their rate-review processes. The American Hospital Association (AHA) issued a statement regarding the new database, citing the “urgent” need for updating the system for setting hospital charges and indicating its continued support for price-transparency legislation (H.R. 1326).  The AHA noted that “the complex and bewildering interplay among ‘charges,’ ‘rates,’ ‘bills’ and ‘payments’ across dozens of payers, public and private, does not serve any stakeholder well, including hospitals.”

Cost-Related Problems Getting Needed Care Are Highest Among Adults with Low and Moderate Incomes in 2012

Notes: FPL refers to federal poverty level. Income levels are for a family of four in 2012.

**Did not fill a prescription; did not see a specialist when needed; skipped recommended medical test, treatment, or follow-up; had a medical problem but did not visit doctor or clinic. *Combines “Uninsured now” and “Insured now, time uninsured in past year.” ^Underinsured defined as insured all year but experienced one of the following: out-of-pocket expenses equaled 10% or more of income; out-of-pocket expenses equaled 5% or more of income if low income (<200% of poverty); or deductibles equaled 5% or more of income.

Source: The Commonwealth Fund: Insuring the Future: Current Trends in Health Coverage and the Effects of Implementing the Affordable Care Act

New Plan for Eradicating Polio

On April 25, the Global Polio Eradication Initiative (led by the World Health Organization, the Centers for Disease Control and Prevention, UNICEF, and Rotary International) released a 6-year “endgame” strategic plan for eradicating polio worldwide by 2018. The plan has four goals: “to detect and interrupt all poliovirus transmission, to strengthen immunization systems and withdraw the oral polio vaccine, to contain poliovirus and certify interruption of transmission, and to plan polio’s legacy.” One of the initiative’s primary objectives is to substitute an injectable polio vaccine for the widely used oral vaccine, in order to reduce the risk of vaccine-derived poliovirus infection. Implementation of the plan will cost an estimated $5.5 billion over the next 6 years and will be supported primarily by the Bill and Melinda Gates Foundation.

FDA Investigates Caffeine as a Food Additive

In response to the growing trend of adding caffeine to foods and beverages, the Food and Drug Administration has announced that it will investigate the safety of caffeine in food products. Michael Taylor, the deputy commissioner for foods and veterinary medicine at the FDA, notes that it will be particularly important to investigate the effects of caffeine additives on children and adolescents. The American Academy of Pediatrics discourages the consumption of caffeine and other stimulants by children and young adults, although the FDA has not yet determined what level of caffeine consumption is safe for children. The agency aims to decide whether it’s appropriate for products marketed to young consumers to contain caffeine and whether it should set limits on the amount of caffeine that can be added to certain products.

Hospice Company Sued for Medicare Fraud

The U.S. Department of Justice recently filed a lawsuit against Chemed Corporation, which owns the large for-profit hospice chain Vitas Hospice Services, for allegedly submitting fraudulent Medicare claims for end-of-life care services since 2002. Vitas provides hospice services to Medicare patients in 18 states. This lawsuit stems from the work of the Obama administration’s Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative and faults Vitas for having “knowingly submitted or caused the submission of false claims to Medicare for crisis care services that were not necessary, not actually provided, or not performed in accordance with Medicare requirements.” Chemed  responded that it intends to “defend this lawsuit vigorously” and noted its “significant investments to uphold the highest industry standards.”

Prostate-Cancer Screening — Updated Guidelines

On May 3, the American Urological Association released revised guidelines for prostate-cancer screening with the prostate-specific–antigen (PSA) test. Even after the U.S. Preventive Services Task Force issued a recommendation against all PSA screening for prostate cancer in May 2012, the AUA maintained its support for the early-detection strategy. The USPSTF based its recommendation on evidence that PSA testing has “very small potential benefit and significant potential harm” for men. The AUA has now pulled back from its previous stance and is advising against PSA screening in men under 40 years of age, men 40 to 54 years of age with average risk for prostate cancer, and men older than 70 who have a life expectancy of less than 10 to 15 more years. For the age group with the highest risk (55 to 69 years), the AUA “strongly recommends shared decision-making . . . and proceeding based on a man’s values and preferences.”

How Would You Replace the SGR?

Last week, Senate Finance Committee Chairman Max Baucus (D-MT) and ranking member Orrin Hatch (R-UT) called on physicians and other health care providers to give input on “viable alternatives” to the controversial sustainable growth rate formula (SGR) used to calculate Medicare’s physician fees. In their letter to health care providers, the senators express their desire to repeal the “broken” SGR and indicate that physician payment reform more broadly will remain a top priority for their influential congressional committee. They urge health care providers to e-mail “specific suggestions” of ways of replacing the SGR, as well as other comments regarding physician payment reform, to sgrcomments@finance.senate.gov by May 31. The committee’s stated goal is for Medicare to “pay physicians and other health care providers in a way that results in high quality, affordable care for

In 2012, Nearly Half of Adults Were Uninsured During the Year or Were Underinsured

Notes: Numbers may not sum to indicated total because of rounding.

*Combines “Uninsured now” and “Insured now, time uninsured in past year.” ^Underinsured defined as insured all year but experienced one of the following: out-of-pocket expenses equaled 10% or more of income; out-of-pocket expenses equaled 5% or more of income if low income (<200% of poverty); or deductibles equaled 5% or more of income.

Source: The Commonwealth Fund: Insuring the Future: Current Trends in Health Coverage and the Effects of Implementing the Affordable Care Act

Eliminating Elective Early Deliveries

On May 1, a coalition of “major players in the delivery of maternity care” released a statement calling for hospital leadership to bring an end to non–medically indicated elective deliveries in the United States. The coalition, which includes the American Hospital Association, the March of Dimes, and organizations representing nurse midwives, family physicians, pediatricians, and obstetricians and gynecologists, urges the 3103 U.S. maternity care hospitals to implement policies to prevent deliveries from taking place prior to 39 weeks of gestation if they are not medically necessary. The letter augments the Strong Start Initiative campaign, launched by the Department of Health and Human Services in February 2012 as a way of bringing attention to this trend. The letter states that “Every hospital that delivers babies — urban and rural, large or small — can make a difference in a child’s life by adopting this policy.

Over-the-Counter Access to Plan B One-Step

The FDA announced last week that it has approved an application by Teva Women’s Health to make the emergency contraceptive Plan B One-Step available without a prescription to girls and women 15 or older.  The product, a single 1.5-mg tablet of levonorgestrel, reduces the possibility of pregnancy after unprotected sex and is most effective if taken soon after intercourse.  Teva had applied in February 2011 for approval for over-the-counter status for Plan B One-Step for all women of reproductive age, but in December of that year Secretary of Health and Human Services Kathleen Sebelius overruled the FDA’s decision to grant that approval, citing concerns that girls as young as 11 would have access to the drug.  More recently, a federal judge in Brooklyn, New York, ruled that Sebelius’s decision was “arbitrary, capricious, and unreasonable.” The FDA stressed that Teva’s new application “was pending with the agency prior to the ruling” and that its approval “is independent of that litigation and . . . not intended to address the judge’s ruling.”

Walgreens Clinics Provide Chronic Disease Care

On April 4, Walgreens announced that its in-store clinics will begin offering assessment, treatment, and management of chronic conditions such as diabetes, asthma, and hypertension. The company cites poor access to health care services, a physician shortage, and a growing population of patients with chronic diseases as motivations for expanding its clinics’ range of services. The American Academy of Family Physicians opposes retail clinics’ moving beyond the treatment of minor acute illnesses to the management of chronic medical conditions. The AAFP’s concerns include the fragmentation of individual patient’s primary care among multiple physicians and retail clinics’ use of “protocol-based decision and diagnostic models,” which it believes result “in a missed opportunity to address more complex patient needs.”

State Medicaid Expansions

With the federal fiscal year ending July 1 and various state legislative calendars concluding even sooner, state leaders have continued to weigh in on whether their states should expand Medicaid coverage, as called for by the Affordable Care Act. Florida Governor Rick Scott (R) had surprised many pundits by indicating that his state would move forward with Medicaid expansion, but Florida’s Republican-led state legislature adjourned last Friday without allocating the funding to do so. West Virginia’s Earl Ray Tomblin became the latest Democratic governor to publicly express support for Medicaid expansion in his state. Meanwhile, Oregon’s experiment with Medicaid expansion has had mixed results:  no significant improvements in measured physical health outcomes so far, but increased use of health care services, higher rates of diabetes detection and management, lower rates of depression, and reduced financial strain.

U.S. Sues Novartis over Alleged Kickbacks

On April 26, the U.S. Department of Justice filed the second civil lawsuit within a week against Novartis, claiming that the drug maker violated the Anti-Kickback Statute by targeting doctors with “lavish dinners” and other events to try to get them to prescribe Novartis products. The civil action seeks damages and civil penalties for prescriptions influenced by these kickbacks that were reimbursed for by federal health care programs, including Medicare. Acting Assistant Attorney General Stuart Delery commented, “Kickback schemes like those alleged in this case not only call into question the integrity of individual medical decisions, they raise the cost of health care for all of us.”  Novartis disputed the allegations in a press release, stating that they “disagree with the way the government is characterizing our conduct in both of these matters and we stand behind our Compliance program.”

H7N9 Influenza Toll Grows

As of May 8, the World Health Organization (WHO) reports, there have been 131 confirmed cases in humans of a novel avian influenza A (H7N9) virus and 32 related deaths.  The patients with the latest confirmed cases are a 79-year-old woman from China’s Jiangxi Province, as well as a 69-year-old man and a 9-year-old boy, both from the Fujian Province. Since the beginning of the month, there have been 14 cases and 9 related deaths.  WHO also released a plan on May 2 for the development, production, and distribution of vaccines to combat the spread of influenza strains with “pandemic potential,” including the H7N9 virus. Chinese investigators have thus far posted 19 partial or complete viral genome sequences to the Global Initiative on Sharing All Influenza Data. The U.S. Centers for Disease Control and Prevention has directed state and local health departments to be vigilant in identifying and observing symptomatic travelers returning from China. Of the 37 such travelers reported to the CDC as of April 29, none were infected with the H7N9 virus.

84 Million Americans Uninsured or Underinsured in 2012

A new survey shows that approximately 84 million people in the United States — 46% of adults 19 to 64 years of age —- were either uninsured or underinsured for some period in 2012. These results, released last week, come from the biennial health insurance survey administered by the Commonwealth Fund, which aims to capture U.S. trends in health insurance coverage.  On the upside, an estimated 1.9 million fewer young adults (19 to 25 years of age) lacked insurance at any point during 2012 than had been uninsured at some point in 2010 — a trend that probably results from the Affordable Care Act provision requiring insurers to cover children up to 26 years old under their parents’ health plan.

Tavenner on Hold; Baucus Out

Two new developments in Washington may have far-reaching implications for the implementation of the Affordable Care Act. Although Marilyn Tavenner received bipartisan support during her confirmation hearing in front of the Senate Finance Committee in early April, her confirmation as administrator of the Centers for Medicare and Medicaid Services came to an unexpected halt last week. Senator Tom Harkin (D-IA) put a temporary hold on the confirmation because he disapproves of the redirection of funds from the Prevention and Public Health Fund to the implementation of the ACA. In a separate development, the chairman of the Senate Finance Committee, Senator Max Baucus (D-MT), announced that he will not run for reelection. Baucus, now in his sixth term, was a key player in the passage of the ACA. He will retire in 2014, the year that major provisions of the law, ranging from state-based insurance exchanges to Medicaid expansions, will be implemented.

CML Experts Criticize $100,000+ Cancer Drugs

Controversy over the prices of cancer drugs hit the lay press last week after a commentary signed by more than 100 experts on chronic myeloid leukemia (CML) decried the “astronomical” prices of certain CML drugs — more than $100,000 per year. The experts acknowledged the “complex societal and political issues” underlying the pricing for such therapies, but they concluded that the prices are “too high, unsustainable, may compromise access of needy patients to highly effective therapy, and are harmful to the sustainability of our national healthcare systems.” The president of Novartis Oncology wrote a response, citing the benefits of CML therapies such as Gleevec (imatinib), and expressing the company’s desire to “be part of the dialogue” on this complex topic.

Bipartisan Cost-Containment Recommendations

Last week, prominent Democratic and Republican leaders released guidelines for achieving a higher-value health care system. The report from the Bipartisan Policy Center’s Health Care Cost Containment Initiative, cochaired by Tom Daschle, Bill Frist, Pete Domenici, and Alice Rivlin, provides a blueprint for getting costs under control and improving quality. Recommendations include creating new “Medicare networks” that attract providers who offer higher-quality, more cost-effective care; scrapping the sustainable growth rate formula for calculating Medicare’s physician fees and replacing it with new payment models; reforming and rationalizing the current tax exclusion for employer-sponsored insurance; asking the Institute of Medicine to study whether evidence-based quality measures can be used to defend providers in medical liability cases; and bolstering initiatives such as workplace wellness programs. The authors note that this initiative differs from others in that it’s bipartisan and “breaks with approaches that prioritize or even focus solely on federal health-costs and deficit reduction.”

Bowles-Simpson 2.0 and Health Care

Deficit-reduction planners Alan Simpson (Republican former senator from Wyoming) and Erskine Bowles (former Clinton White House chief of staff) have called for health care spending cuts of more than $585 billion, in a new plan designed to mitigate the country’s fiscal woes.  “Bowles–Simpson 2.0” outlines steps for achieving approximately $2.5 trillion in savings over the next decade, building on the work of the pair’s 2010 bipartisan National Commission on Fiscal Responsibility and Reform. The roughly half-trillion in proposed health care savings derive from such proposals as raising Medicare’s eligibility age to 67 (with an income-related buy-in option at age 65) — which President Obama has flatly rejected — and instituting Medicaid-level drug rebates for Americans eligible for both Medicare and Medicaid  who obtain prescription drugs through Medicare Part D.  Simpson and Bowles note that Medicare and Medicaid “represent the single greatest threat to our long-term fiscal sustainability” and criticize lawmakers for prioritizing “elections over [fiscal] solutions.”

FDA to Survey Docs about Drug Ads

The White House gave the Food and Drug Administration a green light last Thursday to conduct a survey of health care providers about pharmaceutical industry marketing practices.  The last Healthcare Professional Survey of Prescription Drug Promotion took place in 2002 and showed that one third of physicians thought that direct-to-consumer advertising had a positive effect on their practice, one third thought it had a negative effect, and the rest thought it had no effect. The new survey project — authorized under a provision of the Public Health Service Act allowing the FDA to conduct research — is projected to cost roughly $365,000 over 2 years.  As compared with the 2002 survey, it will “recruit a wider range of prescribers” (including nurse practitioners and physician assistants) and ask a “wider range of questions” regarding both the promotion of pharmaceutical products in professional settings and direct-to-consumer advertising.