The US health care system is among the most advanced in the world. Escalating health care costs resulted in several proposals for a national health care program in the 1970s, early 1980s, and early 1990s. Most reform measures relied either on market-oriented approaches designed to widen insurance coverage through tax subsidies on a federally controlled single-payer plan, or on mandatory employer payments for insurance coverage. At the end of the 1990s, the health care industry was struggling with continued rising costs, as well as the financial burden of providing care to over 40 million people who were uninsured. As of 1998, 44.3 million people, or 16% of the population, were without health insurance coverage. The percentage among the nation's poor was much higher (32%).
In response to rising costs, the popularity of managed care grew rapidly in the latter half of the 1990s. By 2000, 59% of the population was insured by either an HMO (health maintenance organization) or PPO (preferred provider organization). In such organizations, medical treatment, laboratory tests, and other health services for each patient are subject to the approval of the insurer before they can be covered. From 1987 to 1996, enrollment in health maintenance organizations (HMOs) doubled. By the end of the decade, however, the quality of treatment under managed care organizations was coming under increased scrutiny.
Life expectancy for someone born in 2000 was 76.9 years. Males could expect to live 74.1 years, females 79.5 years. Projections for 2010 were an average of 78.5 years for both males and females (males, 75.6; females, 81.4). Infant mortality has fallen from 3,830 per 100,000 live births in 1945 to 848.7 in 1992. In 2000 infant mortality was 7 per 1,000 live births. The birth rate in 2002 was 14.1 per 1,000 people. In 1997, 1,328,000 abortions were performed in the United States. In 1999, 56.5% of US adults were overweight and 21.1% were obese. Although health indicators continued to improve overall in the 1990s, pronounced disparities between different segments of the population remained.
The overall death rate is comparable to that of most nations—an estimated 8.7 per 1,000 people as of 2002. Leading causes of death (total number/rate per 100,000 people) in 2000 were: heart disease (709,894/257.9); cancer (551,833/200.5); cerebrovascular diseases (166,028/60.3); chronic lower respiratory diseases (123,550/44.9); accidents (93,592/34); diabetes mellitus (68,662/24.9); pneumonia and influenza (67,024,/24.3); Alzheimer's disease (49,044/17.8); suicide (28,332/10.3); and homicide (16,137/5.9).
Cigarette smoking has been linked to heart and lung disease; about 20% of all deaths in the United States were attributed to cigarette smoking in 1990. Smoking has decreased overall since the late 1980s. The overall trend in smoking mortality suggests a decrease in smoking among males since the 1960s, but an increase in mortality for female smokers. On 23 November 1998, the Master Settlement Agreement was signed, the result of a lawsuit brought by 46 states and the District of Columbia against tobacco companies for damages related to smoking. Payments from the settlement, totaling $206 billion, began in 1999.
The rate of HIV infection (resulting in acquired immune deficiency syndrome—AIDS), first identified in 1981, has risen in the intervening years. There were a cumulative total of 750,000 AIDS cases in the 1980s and 1990s, with 450,000 deaths from the disease. In the latter 1990s, both incidence and mortality decreased with the introduction of new drug combinations to combat the disease. The number of AIDS cases declined by 30% between 1996 and 1998 and deaths were cut in half. In 1999, the number of people living with HIV/AIDS was estimated at 850,000, with the number of deaths from AIDS that year estimated at 20,000 and the number of new HIV infections estimated at 40,000 annually. AIDS continued to affect racial and ethnic minorities disproportionately. In the same year, the breakdown of men reporting new HIV infections was 50% black, 20% Hispanic, 30% white. The breakdown for new cases among women was 64% black, 18% Hispanic, 18% white. As of 1999, 50% of new infections were in found in homeosexual men; 25% were in injecting drug users. HIV prevalence was 0.6 per 100 adults in 1999.
Medical facilities in the United States included 5,810 hospitals in 2000, with 984,000 beds (down from 6,965 hospitals and 1,365,000 beds in 1980). In the same year, there were 813,800 physicians. Of the total number of active classified physicians, the largest areas of activity were internal medicine, 88,700; general and family practice, 67,500; pediatrics, 42,200; obstetrics and gynecology, 31,700; and general surgery, 24,500. As of 2000, there were 2,697,000 registered nurses. Dentists numbered approximately 170,000. As of 1999, there were an estimated 2.7 physicians and 3.6 hospital beds per 1,000 people.
Per capita health care expenditures rose from $247 in 1967 to about $3,380 in 1993. National health care spending reached $1 trillion in 1996 and is projected to rise to $1.8 trillion by 2005. Hospital costs, amounting to over $371 billion in 1997, represented 34% of national health care spending in that year. In the late 1990s, total health care expenditures stabilized at around 13% of GDP, with most expenditures being made by the private sector.
Medicare payments have lagged behind escalating hospital costs; payments in 2000 totaled $215.9 billion. Meanwhile, the elderly population in the United States is projected to increase to 18% of the total population by 2020, thus exacerbating the conundrum of health care finance. As of June 1999, 39 states had adopted policies enabling Medicaid funds to be used to cover medical services for qualified individuals requiring services provided by assisted-living facilities.