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Tackling the burden of chronic diseases in the USA
Editorial
The January/February, 2009, issue of Health Affairs explores the escalating burden of chronic diseases currently afflicting the USA. Data from 2005 show that 44% of all Americans have at least one chronic condition and 13% have three or more. By 2020, 157 million US citizens are predicted to have more than one chronic disorder, with 81 million having multiple conditions. Chronic disorders include diabetes, hypertension, hyperlipidaemia, heart failure, depression, arthritis, and cancer, among others. The most common chronic diseases in adults in the USA are hypertension, hyperlipidaemia, and diabetes. However, long-term conditions are also affecting the country’s children; one in three is predicted to develop diabetes, largely owing to obesity. The number of patients with diabetes is set to double in the next 25 years (from 24 million to 48 million), and similar predictions have been made for most chronic conditions. Currently, two-thirds of all deaths in the USA are attributable to one of five chronic disorders: cancer, chronic obstructive pulmonary disease, diabetes, heart disease, and stroke. So why has the USA seen such an increase in the burden of chronic disease? An ageing population is a major contributor; the population of five million elderly people in 2005 is estimated to reach 21 million by 2050. The prevalence of chronic conditions increases with advancing age, which means that Americans over 64 years carry the greatest disease burden (45% of 65–79-year-olds and 54% of those over 80 years have multiple chronic disorders). The other major influence is the increasingly sedentary and unhealthy lifestyles of younger Americans, which have contributed to a doubling between 1996 and 2005 in the number of people aged 20–44 years with more than one chronic disease. Three-quarters of health-care expenditure in the USA is on chronic disease bills (US$1·7 trillion per year) and 76% of Medicare expenditure goes to beneficiaries with more than five chronic conditions. The rising prevalence of these diseases has also resulted in bigger out-ofpocket expenses for citizens. Drugs are the costliest outof-pocket outlay—people over 65 years with multiple chronic diseases spend on average $1292 a year on medicines . Evidently, changes need to be made if the US health system is to cope with the spiralling burden of multiple www.thelancet.com Vol 373 January 17, 2009
chronic diseases. WHO believes that 80% of chronic disorders could be eliminated by the implementation of appropriate preventive measures. Currently, less than 4 cents of every dollar spent on health care in the USA goes on preventive and public-health measures. Encouragingly, Barack Obama, who will assume office as the US President this week, has included the promotion of prevention and the strengthening of public-health strategies in his three-part plan for the improvement of the US health system. Obama has pledged to increase worksite health programmes and to involve schools in raising prevention awareness (eg, with better education and nutritious food options). He plans to insist that federally supported health insurance must cover preventive care, and that all Americans should have access to preventive services such as cancer screening. He promises funding to create healthier environments to live in, with increased cycle trails and parks, and he has pledged to increase funding for appropriately trained primary-care physicians. Obama’s proposals to raise sales taxes on packets of cigarettes and to ratify the international anti-tobacco treaty are also welcome steps towards prioritising chronic-disease prevention. The situation in the USA is worse than in European countries where there is a lower prevalence of cardiac disease, diabetes, and other chronic conditions, partly because of healthier diets and lower rates of poverty. The USA also has the most expensive chronic-disease care system, and US citizens have less access to care than those across the Atlantic—47 million Americans lack individual health insurance. The new US President is right to prioritise the burden of chronic diseases, but responsibility for reversing the rise in prevalence of these conditions also lies with every physician. All US citizens should be encouraged to adopt a healthier lifestyle. However, preventive care is not the only way to tackle chronic diseases; insurance and payment systems must be strengthened to ensure they can cope with the rising burden of chronic conditions, and measures need to be implemented to support and care for the increasingly elderly population. Chronic diseases are the greatest health threat facing the USA today. The new government must act wisely, to prevent this epidemic from crippling the nation. ■ The Lancet
Photolibrary
Tackling the burden of chronic diseases in the USA
For the Health Affairs special issue on The Crisis in Chronic Disease see http://content. healthaffairs.org/
185
The January/February, 2009, issue of Health Affairs explores the escalating burden of chronic diseases currently afflicting the USA. Data from 2005 show that 44% of all Americans have at least one chronic condition and 13% have three or more. By 2020, 157 million US citizens are predicted to have more than one chronic disorder, with 81 million having multiple conditions. Chronic disorders include diabetes, hypertension, hyperlipidaemia, heart failure, depression, arthritis, and cancer, among others. The most common chronic diseases in adults in the USA are hypertension, hyperlipidaemia, and diabetes. However, long-term conditions are also affecting the country’s children; one in three is predicted to develop diabetes, largely owing to obesity. The number of patients with diabetes is set to double in the next 25 years (from 24 million to 48 million), and similar predictions have been made for most chronic conditions. Currently, two-thirds of all deaths in the USA are attributable to one of five chronic disorders: cancer, chronic obstructive pulmonary disease, diabetes, heart disease, and stroke. So why has the USA seen such an increase in the burden of chronic disease? An ageing population is a major contributor; the population of five million elderly people in 2005 is estimated to reach 21 million by 2050. The prevalence of chronic conditions increases with advancing age, which means that Americans over 64 years carry the greatest disease burden (45% of 65–79-year-olds and 54% of those over 80 years have multiple chronic disorders). The other major influence is the increasingly sedentary and unhealthy lifestyles of younger Americans, which have contributed to a doubling between 1996 and 2005 in the number of people aged 20–44 years with more than one chronic disease. Three-quarters of health-care expenditure in the USA is on chronic disease bills (US$1·7 trillion per year) and 76% of Medicare expenditure goes to beneficiaries with more than five chronic conditions. The rising prevalence of these diseases has also resulted in bigger out-ofpocket expenses for citizens. Drugs are the costliest outof-pocket outlay—people over 65 years with multiple chronic diseases spend on average $1292 a year on medicines . Evidently, changes need to be made if the US health system is to cope with the spiralling burden of multiple www.thelancet.com Vol 373 January 17, 2009
chronic diseases. WHO believes that 80% of chronic disorders could be eliminated by the implementation of appropriate preventive measures. Currently, less than 4 cents of every dollar spent on health care in the USA goes on preventive and public-health measures. Encouragingly, Barack Obama, who will assume office as the US President this week, has included the promotion of prevention and the strengthening of public-health strategies in his three-part plan for the improvement of the US health system. Obama has pledged to increase worksite health programmes and to involve schools in raising prevention awareness (eg, with better education and nutritious food options). He plans to insist that federally supported health insurance must cover preventive care, and that all Americans should have access to preventive services such as cancer screening. He promises funding to create healthier environments to live in, with increased cycle trails and parks, and he has pledged to increase funding for appropriately trained primary-care physicians. Obama’s proposals to raise sales taxes on packets of cigarettes and to ratify the international anti-tobacco treaty are also welcome steps towards prioritising chronic-disease prevention. The situation in the USA is worse than in European countries where there is a lower prevalence of cardiac disease, diabetes, and other chronic conditions, partly because of healthier diets and lower rates of poverty. The USA also has the most expensive chronic-disease care system, and US citizens have less access to care than those across the Atlantic—47 million Americans lack individual health insurance. The new US President is right to prioritise the burden of chronic diseases, but responsibility for reversing the rise in prevalence of these conditions also lies with every physician. All US citizens should be encouraged to adopt a healthier lifestyle. However, preventive care is not the only way to tackle chronic diseases; insurance and payment systems must be strengthened to ensure they can cope with the rising burden of chronic conditions, and measures need to be implemented to support and care for the increasingly elderly population. Chronic diseases are the greatest health threat facing the USA today. The new government must act wisely, to prevent this epidemic from crippling the nation. ■ The Lancet
Photolibrary
Tackling the burden of chronic diseases in the USA
For the Health Affairs special issue on The Crisis in Chronic Disease see http://content. healthaffairs.org/
185