Contents

1. Summary Measures of Population Health ........................................................ 1

1.1 Introduction ............................................................................... 1

1.2 Overview of the Role of Summary Measures in Health............................................ 2

1.2.1 The process of population health change ................................................... 2

1.2.2 Past use of summary measures ........................................................... 3

1.3 Potential Summary Measures Suggested for Healthy People 2010 ................................... 5

1.4 Availability of Data for Estimating the Proposed Measures......................................... 6

References ................................................................................... 7

2. Methods for Calculating Healthy Life Expectancy................................................. 8

2.1 Introduction ............................................................................... 8

2.2 The Life Table Technique .................................................................... 8

2.2.1 Estimating the average expectation of life .................................................. 8

2.2.2 Estimating healthy life expectancy ........................................................ 9

2.2.3 Standard errors of healthy life expectancy .................................................. 11

References ................................................................................... 11

3. Expected Years of Healthy Life Under Various Definitions of Health ................................ 13

3.1 Introduction ............................................................................... 13

3.2 Expected Years of Healthy Life for Males and Females............................................ 13

3.2.1 Expected years in good or better health ................................................... 13

3.2.2 Expected years without activity limitation .................................................. 14

3.2.3 Expected years without work limitation ................................................... 15

3.2.4 Expected years without functional dependency .............................................. 15

3.2.5 Expected years without diseases or chronic conditions ........................................ 17

3.2.6 Expected years with body mass index (BMI) less than 25 and years with BMI less than 30 ......... 18

3.3 Expected Years of Healthy Life for the White and Black Populations ................................ 20

3.3.1 Expected years in good or better health for the white and black populations ...................... 20

3.3.2 Expected years without any activity limitation for the white and black populations................. 21

3.3.3 Expected years without ADL or IADL limitation for the white and black populations............... 22

3.3.4 Expected years with BMI less than 30 for the white and black populations ...................... 22

3.4 Comparison of Results from the Various Measures of Health ....................................... 24

3.4.1 Comparison across measures at 30 and 65 years of age ....................................... 25

3.4.2 Comparison across measures for males and females at 65 years of age........................... 25

3.4.3 Comparison across measures for the white and black populations at 65 years of age ............... 27

3.4.4 Comparison across measures by age, sex, and race ........................................... 27

References ................................................................................... 28

iii
4. Trends in Life Free of Activity Limitation: United States, 1985–95................................... 42

4.1 Introduction ............................................................................... 42

4.2 Age-Adjusted Death and Activity Limitation Rates: United States, 1985–95 ........................... 42

4.3 Age-Specific Death and Activity Limitation Rates: United States, 1985 and 1995 ...................... 43

4.4 Years Free of Activity Limitation: United States, 1985–95 ......................................... 44

4.5 Gains in Life Expectancy and Expected Limitation-Free Years: United States, 1985–95.................. 45

4.6 Summary ................................................................................. 46

References ................................................................................... 47

5. The Impact of Incomplete Data on Healthy Life Expectancy Estimates .............................. 52

5.1 Introduction ............................................................................... 52

5.2 The 1995 Noninstitutionalized Civilian and Institutionalized Populations.............................. 53

5.2.1 The noninstitutionalized civilian population ................................................. 54

5.2.2 The 1995 nursing home population........................................................ 54

5.3 Functional Limitation: The Community and Nursing Home Populations .............................. 54

5.3.1 Functional limitation: The population 5 years of age and over.................................. 55

5.3.2 Functional limitation: The population 65 years of age and over ................................ 56

5.4 Effect on Healthy Life Expectancy Estimates for the Older Population ............................... 57

References ................................................................................... 58

6. Summary and Conclusion ..................................................................... 62

References ................................................................................... 64

Figures

1.1 Population health change .................................................................... 2

1.2 Potential health changes for individuals ......................................................... 3

1.3 Health care and public health intervention opportunities ............................................ 4

2.1 A schematic presentation of the model ......................................................... 9

2.2 A schematic framework for estimating healthy life expectancy at the national level using respondentassessed health status as an example ........................................................... 10

2.3 Example of attributes for health classification system ............................................. 10

3.1 Percentage of persons reporting good or better health, by age and sex: United States, 1995 ............... 14

3.2 Percentage of expected life in good or better health at birth, 20, and 65 years of age, by sex:

United States, 1995.......................................................................... 14

3.3 Percentage free of activity limitation, by age and sex: United States, 1995 ............................ 15

3.4 Percentage of life expectancy free of any activity limitation at birth, 20, and 65 years of age, by sex:

United States, 1995 ......................................................................... 16

3.5 Percentage able to perform personal care needs or not limited in other routine needs, by age and sex:

United States, 1995 ......................................................................... 16

3.6 Percentage of life expectancy able to perform personal care needs or not limited in other routine

needs at 45, 65, and 75 years of age, by sex: United States, 1995 .................................... 17

3.7 Percentage of life expectancy free of chronic arthritis at 30, 65, and 75 years of age, by sex:

United States, 1994–96 ...................................................................... 18

3.8 Percentage of life expectancy free of chronic heart diseases at 30, 65, and 75 years of age, by sex:

United States, 1994–96 ...................................................................... 18

iv
3.9 Percentage of life expectancy free of chronic hypertension at 30, 65, and 75 years of age, by sex:

United States, 1994–96 ...................................................................... 18

3.10 Percentage not obese, by age and sex: United States, 1994–96 ...................................... 19

3.11 Percentage in good or better health, by age and race: United States, 1995 ............................. 21

3.12 Percentage free of any type of activity limitation, by age and race: United States, 1995 .................. 22

3.13 Percentage able to perform personal care needs or not limited in other routine

needs, by age and race: United States, 1995 ..................................................... 23

3.14 Percentage not obese, by age and race: United States, 1994–96 ..................................... 23

3.15 Life expectancy and expected years of healthy life under different definitions of health at 30 years of

age, both sexes: United States, 1995 ........................................................... 24

3.16 Life expectancy and expected years of healthy life under different definitions of health at 65 years of

age, both sexes: United States, 1995 ........................................................... 25

3.17 Life expectancy and expected years of healthy life for males under different definitions of health at

65 years of age: United States, 1995............................................................ 26

3.18 Life expectancy and expected years of healthy life for females under different definitions of health at

65 years of age: United States, 1995 ........................................................... 26

3.19 Life expectancy and expected years of healthy life for the white population under different definitions of

health at 65 years of age: United States, 1995 ................................................... 27

3.20 Life expectancy and expected years of healthy life for the black population under different definitions of

health at 65 years of age: United States, 1995 ................................................... 27

3.21 Sex disparities in health under various definitions of health status, by age: United States, 1995 ........... 28

3.22 Racial disparities in health between white and black populations under various definitions of health status,

by age: United States, 1995 .................................................................. 29

4.1 Number of deaths per 1,000 for white males, by age: United States, 1985 and 1995 ..................... 43

4.2 Number of deaths per 1,000 for white females, by age: United States, 1985 and 1995 ................... 43

4.3 Number of deaths per 1,000 for black males, by age: United States, 1985 and 1995 ..................... 44

4.4 Number of deaths per 1,000 for black females, by age: United States, 1985 and 1995 ................... 44

4.5 Percentage of white males with activity limitation from any cause, by age: United States, 1985

and 1995 ................................................................................. 44

4.6 Percentage of white females with activity limitation from any cause, by age: United States, 1985

and 1995 ................................................................................. 45

4.7 Percentage of black males with activity limitation from any cause, by age: United States, 1985

and 1995 ................................................................................. 45

4.8 Percentage of black females with activity limitation from any cause, by age: United States, 1985

and 1995 ................................................................................. 46

4.9 Expected years free of activity limitation as percentage of life expectancy, white males: United States,

1985 and 1995 ............................................................................. 46

4.10 Expected years free of activity limitation as percentage of life expectancy, white females: United States,

1985 and 1995 ............................................................................. 46

4.11 Expected years free of activity limitation as percentage of life expectancy, black males: United States,

1985 and 1995 ............................................................................. 47

4.12 Expected years free of activity limitation as percentage of life expectancy, black females: United States,

1985 and 1995 ............................................................................. 47

5.1 Percentage of the female population 65 years of age and over who need help with at least one activity of

daily living, by age and residence: United States, 1995............................................. 54

5.2 Percentage of the female population 65 years of age and over who need help with at least one

instrumental activity of daily living, by age and residence: United States, 1995 ........................ 55

5.3 Percentage of the female population 65 years of age and over who need help with at least one activity

of daily living, by age and residence: United States, 1995 .......................................... 56

5.4 Percentage of the female population 65 years of age and over who need help with at least one activity

of daily living or instrumental activity of daily living, by age and residence: United States, 1995 .......... 57

v
Text Tables

A. Rates per thousand with chronic condition, by type of condition and sex at selected ages: United States,

1994–96................................................................................... 17

B. Classification of overweight and obesity by body mass index (BMI): Adults, 18 years of age and over ..... 19

C. The community and institutionalized population, by sex: United States, 1990 .......................... 52

D. Percentage distribution of the noninstitutionalized and institutionalized population, by broad age group:

United States, 1990 ......................................................................... 53

E. Percentage distribution and sex ratio of community dwellers and the nursing home population, by broad age

group: United States, 1995 ................................................................... 53

Detailed Tables

3.1. Life expectancies and expected years in good or better health and excellent health for selected ages,

by sex: United States, 1995 ................................................................... 30

3.2. Life expectancies and expected years without limitation in activity for selected ages, by sex and type of

activity: United States, 1995 .................................................................. 31

3.3. Life expectancies and expected years without work limitation for selected ages, by sex:

United States, 1995 ......................................................................... 32

3.4. Life expectancies and expected years without functional dependency for selected years, by sex:

United States, 1995.......................................................................... 33

3.5. Life expectancies and expected years without chronic arthritis and chronic heart diseases for selected ages,

by sex: United States, 1994–96 ................................................................ 34

3.6. Life expectancies and expected years without chronic hypertension and chronic diabetes for selected ages,

by sex: United States, 1994–96 ................................................................ 35

3.7. Life expectancies and expected years with body mass index less than 25 and years with body mass index

less than 30 for selected ages, by sex: United States, 1994–96....................................... 36

3.8. Life expectancies and expected years in good or better health for selected ages of the white and black

populations, by sex: United States, 1995 ........................................................ 37

3.9. Life expectancies and expected years without any type of activity limitation for selected ages of the

white and black populations, by sex: United States, 1995 ........................................... 38

3.10. Life expectancies and expected years without limitation in personal care or other routine needs for

selected ages of the white and black populations, by sex: United States, 1995 .......................... 39

3.11. Life expectancies and expected years with body mass index less than 30 for selected ages of the white

and black populations, by sex: United States, 1994–96 ............................................. 40

3.12. Expected years at age 30 and 65 estimated using different definitions of health, by health status:

United States, 1995 ......................................................................... 40

3.13. Expected years at age 65 estimated using different definitions of health, by health status and sex:

United States, 1995.......................................................................... 41

3.14. Expected years at age 65 estimated using different definitions of health, by health status and race:

United States, 1995.......................................................................... 41

4.1. Age-adjusted death rates for all ages, by race and sex: United States, 1985–95 ......................... 48

4.2. Age-adjusted activity limitation rates from any cause for all ages, by race and sex:

United States, 1985–95....................................................................... 48

4.3. Number of deaths from all causes for the white and black populations, by sex: United States, 1985

and 1995 .................................................................................. 49

4.4. Limitation of activity from any cause for the white and black populations, by sex: United States, 1985

and 1995 .................................................................................. 49

4.5. Life expectancy and expected years free of any activity limitation for males at birth, by race:

United States, 1985–95....................................................................... 50

4.6. Life expectancy and expected years free of any activity limitation for females at birth, by race: United States,

1985–95................................................................................... 50

vi
4.7. Life expectancy and expected years free of any limitation at birth, age 20, and age 65 for the white and black

populations, by sex: United States, 1985 and 1995 ................................................ 51

5.1. Number and percentage distribution of community residents by sex and by race, according to age at

interview: United States, 1995 ................................................................. 59

5.2. Number and percentage distribution of nursing home residents by sex and by race, according to age at

interview: United States, 1995 ................................................................. 59

5.3. Percentage of population needing help with at least one activity of daily living and needing help with at

least one activity of daily living or instrumental activity of daily living, by broad age group, sex, and place

of residence: United States, 1995 .............................................................. 60

5.4. Percentage of population needing help with at least one activity of daily living, by age, sex, and place

of residence: United States, 1995 .............................................................. 60

5.5. Percentage of population needing help with at least one activity of daily living or instrumental activity

of daily living, by age, sex, and place of residence: United States, 1995............................... 61

5.6. Expected years of life and healthy years of female community dwellers and nursing home residents at

selected ages: United States, 1995.............................................................. 61

6.1. Absolute and relative differences in male and female healthy life expectancy at 30 and 65 years of age:

United States, 1995.......................................................................... 65

6.2. Absolute and relative differences in male and female healthy life expectancy for the white and black

populations at 30 and 65 years of age: United States, 1995 ......................................... 66

vii
1. Summary Measures of Population Health

1.1 Introduction

The concept of health expectancy was introduced in the 

1960s (1) and further developed in the 1970s (2–4). In more 

recent years, both policy makers and members of the 

research community have been increasingly interested in the 

estimation of healthy life expectancy. This interest arises 

from the fact that measures of healthy life expectancy 

potentially offer easily comprehensible measures of both the 

level of, and change in, the well-being of a population. 

Because these measures incorporate both mortality and 

morbidity, they seem highly appropriate as summary 

measures of health in the older population, where there has 

been considerable mortality decline, but where there is 

concern that the extension of life may not be equivalent to 

the extension of healthy life. 

The relationship between changes in mortality and 

morbidity and the relatively greater burden of morbidity in 

the older ages gained interest in the 1980s. Debate centered 

on whether the factors responsible for the reductions in 

mortality would have a similar effect on morbidity. Some 

argued that most of the years of life that the elderly gained 

due to the decline of mortality were ‘‘healthy years’’ either 

because the incidence of chronic conditions was being 

pushed to the last few years of life, that is, the compression 

of morbidity (5,6) or because the loss of functioning or 

disability from chronic conditions had slowed down (7). 

Others argued that the medical care improvements that saved 

lives were not accompanied by either disease prevention that 

would maintain healthy states or health care that would 

delay functional consequences of disease (8). 

Healthy life expectancy is also perceived as a useful tool 

for health planning and making health-related policy 

decisions. An indication of the perceived usefulness for 

policy makers of the concept of healthy life expectancy is 

the fact that ‘‘years of active life’’ are now included among 

national and international health goals. For the year 2000, 

the U.S. goal was 65 years of active life expectancy at birth 

for the total population (9). The two overarching national 

health goals identified for Healthy People 2010 are to: 

+ Increase the quality and years of healthy life and 

+ Eliminate health disparities (10). 

The goals and objectives outlined for the decade in 

Healthy People have become central to both monitoring the 

Nation’s health and planning an agenda to promote health 

and prevent ill-health. Monitoring the goals and objectives 

for the year 2010 will, in part, be achieved through Leading 

Health Indicators, a small number of measures that address 

major determinants of health. These Leading Health 

Indicators provide a way of understanding health in the 

future, but there also has been a need to describe, in a 

summary way, the current health of the population. 

Some summary measures combine both the quality and 

quantity of life to reflect years of health and can be used to 

monitor progress toward the first of the overarching goals. 

Because they are comparable across populations with 

different age structures, these measures also can be useful 

for monitoring progress toward the second goal of 

eliminating health disparities. More specifically, summary 

measures of population health combine age-specific 

schedules of health and mortality to derive global measures 

of population health that reflect both mortality and 

morbidity; in this way, expected years of life can be divided 

into healthy and unhealthy life. They have been proposed as 

the most comprehensive measures for evaluating overall 

trends and differences in population health. 

As an initial effort in the development of summary 

measures of health, the National Center for Health Statistics 

(NCHS), Centers for Disease Control and Prevention, 

sponsored a workshop entitled ‘‘Identifying Summary 

Measures for Healthy People 2010’’ on September 17–18, 

1998, at the University of Maryland’s University College 

Conference Center. The purpose of this workshop was to 

identify a set of ‘‘summary’’ measures that could be used to 

evaluate progress toward the overall goals of Healthy People

2010. 

The central question addressed at this workshop was how 

to best characterize the process of health change and 

differentials in a set of summary measures that could be 

estimated reliably and potentially used by Federal and State 

governments to determine trends as well as differences in 

health by age, gender, race or ethnicity, and geographic area. 

The objectives of the workshop were to: 

+ Provide a brief overview of the role of summary 

measures in Healthy People 2000/2010, including 

reporting requirements and data constraints; 

+ Identify a set of potential summary measures that should 

be considered for monitoring progress toward the first 

goal of Healthy People 2010; 

+ Specify ability to compute the potential measures with 

existing data collection systems or cost-effective 

modifications to existing data that would allow the 

computation of measures; and 

+ Specify a research agenda for the next decade to evaluate 

potential summary measures. 

This report presents the findings of research that was 

initiated in response to the workshop recommendations. The 

Summary Measures of Population Health 1
work focuses on methodologic and data issues. The report 

provides definitions of concepts and methods for calculating the 

recommended summary measures; evaluates a number of 

possible measures of morbidity; reviews the trends over a 

decade for one measure of healthy life expectancy; and 

examines the effect of combining data from different sources. 

1.2 Overview of the Role of Summary

Measures in Health

This chapter summarizes conceptual material about 

health and mortality that is identified, summarized, 

measured, and tracked with summary measures. In order to 

identify the prospective summary measures that best monitor 

the quality and years of healthy life (i.e., one of the 

overarching goals of Healthy People 2010) it is necessary to 

first clarify the dimensions of population health and show 

how they are related to health behaviors and potential 

interventions. 

Mortality often has been used as a basic indicator of 

health. Life expectancy is the most frequently used summary 

measure of mortality conditions because it summarizes 

mortality rates across the entire age range. Two 

characteristics of life expectancy make it a valuable measure 

for portraying mortality conditions to audiences that include 

the general public and policy makers. First, it is not affected 

by population age-structure. This means that values can be 

compared for different subgroups of the population at one 

point in time or for the same groups at different points in 

time. In addition, because life expectancy is expressed in 

years of life, it is easily interpreted by both policy makers 

and the public. Both of these characteristics make life 

expectancy an essential tool for monitoring both trends and 

differences in mortality for the population and subgroups of 

the population. Consequently, extending this statistical 

concept to incorporate various states of health may generate 

acceptable and understandable statistics. 

The extension of the basic life table model to include 

measures of health can be used to create summary measures 

of population health that divide expected life into healthy 

and unhealthy years (11,12). When health status is dominated 

by chronic conditions at older ages rather than infectious 

diseases at younger ages, it is possible to have both longer 

life and deteriorating population health (13). For instance, if 

increased treatment of heart disease results in mortality 

decline, people will live longer with the disease; this, in 

turn, will result in increased heart disease prevalence, 

especially if new cases are not prevented. If the years of life 

lived with heart disease continue to be characterized by 

diminished functioning, overall population health will 

deteriorate as life expectancy increases. 

The association between mortality change and health 

change is weakened further because many causes of 

morbidity are not fatal conditions. For instance, osteoarthritis 

is among the leading causes of disability among older 

people, but it is not a likely cause of death. As mortality 

from other causes declines, osteoarthritis prevalence could 

increase. Summary measures that combine mortality and 

morbidity attempt to capture these aspects of health status. 

1.2.1 The process of population health change

The key issue in developing summary measures is 

defining and measuring health and health change. Individual 

researchers and international groups have done significant 

work in defining the dimensions of health and clarifying the 

process of population health change (14,15). A conceptual 

outline of the dimensions of health and the process of 

change in population health is shown in figure 1.1 (16). Any 

or all of the dimensions of health could be captured in 

summary measures. 

Diseases, conditions, and impairments (e.g., heart 

disease, arthritis, and visual impairment) occur before there 

is a loss in functioning or the ability to perform certain 

actions (e.g., walking a block, climbing a specific number of 

stairs, or sitting for an allotted time). Functioning loss can 

then result in disability or an inability to perform an 

expected social role, often defined as work for the 

middle-aged and self-care or independent living for an older 

population. Death is the end of the process. Over time, 

change can occur in some or all of these dimensions, that is, 

getting or living with diseases, experiencing functioning loss, 

and dying (17). 

Disability in this context refers to the situation in which 

an individual’s abilities or limitations are determined by the 

interaction of their physical, mental, or cognitive status with 

the environment in which they would perform social roles. 

The degree of limitation or disability is dependent on how 

Figure 1.1. Population health change

SOURCE: Verbrugge and Jette. ‘‘The Disablement Process.’’ Social Sciences

and Medicine, 1994.

2 Summary Measures of Population Health
well the personal environment accommodates the loss in 

functioning. This definition is equivalent to that developed in 

the Institute of Medical Model (18) and similar to the 

participation dimension of the International Classification of 

Functioning, Disability and Health. In other contexts, 

disability is used to refer to the physical, mental, or 

cognitive status of the individual. Although considerable 

work has been done over the last few years toward 

clarifying the meaning of disability, there is still some 

confusion involving terminology. However, researchers are 

coming to more of a consensus that disability is a complex 

phenomenon and that neither of the definitions outlined 

above adequately describes all the characteristics of the 

phenomenon. 

This scheme is only appropriate for population health 

change, not individual life cycle change. The complexity of 

change at the individual level is shown in figure 1.2. Each 

arrow represents a potential health change for an individual. 

The sum of these changes across all individuals is, of 

course, what produces change in the population. Any 

individual can skip stages and may not necessarily 

experience any stage other than death. Individuals can also 

experience change in both directions, that is, they may 

become impaired and may regain functioning. For 

populations, however, the order of health change in 

figure 1.1 is appropriate; on average, disease occurs first, 

followed by functioning loss and disability, and finally, 

death. The difference between individuals and populations is 

important in evaluating the type of data and methods used 

for summary measures. Information on the individual 

processes requires longitudinal data and methods; 

information on the population may be collected as 

cross-sectional information. 

1.2.2 Past use of summary measures

Summary measures of population health can be 

categorized into two major groups. The first major group of 

measures is called health expectancy (HE), and includes 

measures such as disability-free life expectancy (DFLE) and 

healthy life expectancy (HLE). The second major group, 

which measures health gaps, includes health measures such 

as disability-adjusted life expectancy (DALY) (19). Although 

the summary measures that indicate years of healthy and 

non-healthy life derived from these two general approaches 

(and their myriad variations) may look similar to the 

consumer of the research findings, summary measures 

currently in use are based on a variety of health outcomes, 

assumptions, and methods. These differences are important 

because they relate to the validity and reliability of the 

measures. Because the outcomes of all measures appear 

similar and are expressed in years of life, they may all be 

equally acceptable to the general public; however, 

researchers evaluate the potential uses of the indices quite 

differently. Summarizing health is made considerably more 

complex by the need for multiple measures and the need to 

look at healthy life as measured in both years and as a 

percentage of remaining life spent in the healthy state. This 

evidence supports the conclusion that there are no simple 

measures of health. 

Healthy life expectancy (HLE)—This summary measure 

that links health dimensions and mortality was proposed 

more than 30 years ago (1,3). The methods developed by 

Sullivan, at NCHS, have been adopted worldwide and are 

the basis for the HLE family of measures (20). (See chapter 

2 for details of the methodology.) A substantial body of 

work using Sullivan’s proposed summary measures and with 

modifications to fit available data has been developed over 

the last 10 years. Modifications to the original formulation 

are due to the specific dimension of health used in defining 

healthy life. Often applications of this method have been 

determined by available data more than any clear theoretical 

idea of what aspect of health is appropriate. Most of this 

research has focused on comparing length of life in different 

health states at various points in time and across population 

groups at one point in time. 

The originally proposed measure linked mortality to 

measures of long- and short-term disability to estimate life 

with and without disability using data from the National 

Figure 1.2. Potential health changes for individuals

Summary Measures of Population Health 3
Health Interview Survey (NHIS) (3). Years lived with 

disability could be further divided into severe or moderate 

disability and years of life in an institution. 

In the last 10 years, a number of additional approaches 

to measuring healthy life expectancy using different 

generalizations of disability or health have been developed. 

For instance, in the older population, disability has often 

been indicated by the inability to perform Activities of Daily 

Living (ADL) or Instrumental Activities of Daily Living 

(IADL), tasks which reflect an inability to live 

independently. Other estimates of healthy life expectancy 

have been based on measures that categorize years of life 

using disease states or loss of cognitive functioning as 

measures of health state. For example, healthy life is 

estimated as years without heart disease or years without 

impaired cognitive functioning or dementia. 

Measures of healthy life expectancy have been used to 

track and explain changes in population health. For example, 

research by Crimmins and associates has shown that the 

1980s were a period when increases in life expectancy were 

concentrated in years without disability; in contrast, gains in 

life expectancy during the 1970s were in disabled years. 

This approach has also been important in determining age, 

socioeconomic, and racial differentials (21,22). Hayward 

and Heron (1999) have looked at the relationship between 

disability and life expectancy for ethnic groups in the 

United States; their research has shown that some ethnic 

groups have longer life but worse health (Native 

Americans) than the non-Hispanic white population, while 

others have longer life and better health (Asian 

Americans) (23). 

The healthy life expectancy measures described above 

incorporate nominally defined states of health, and they 

estimate life with and without health in these nominally 

defined states. In order to expand the range of health 

included in the definition of healthy life, some researchers 

have weighted states of health according to an index of 

health problem severity. Measures of healthy life developed 

in this manner may weight states that characterize one 

dimension of health or combine health dimensions into states 

which are weighted to produce a multidimensional index of 

healthy life expectancy. These measures, often called 

Health-Adjusted Life Expectancies (HALE) or 

Health-Adjusted Life Years (HALY), can use a wide variety 

of dimensions to define a set of health states to which the 

weighting scheme is then applied. These include social 

functioning, cognitive functioning, social activities, 

psychological function, pain and symptoms, as well as loss 

in function and disability. The weighting schemes provide a 

number ranging from 0 to 1 to reflect the quality of life or 

the social utility of the health state individuals 

experience (24). Optimal health is valued at 1; death is 

valued at 0. These measures are then integrated with life 

tables to produce health-adjusted life expectancy. Because 

the weights are so important in determining the outcome, 

and because they have great social significance, much effort, 

discussion, and evaluation has gone into producing the 

weighting schemes for use in these measures. Agreement has 

not been reached, however, on the validity of the various 

schemes. 

In summary, measures reflecting healthy life expectancy 

can be based on a variety of definitions of health and can 

utilize a variety of methods. No single measure has been 

agreed upon as the best approach. The appropriateness of 

measures depends on the dimensions of health of primary 

interest (e.g., disability or disease). If there is a desire to link 

these measures to health policies and programs and to 

individual health behaviors, the points of intervention in the 

health process should be considered (figure 1.3). Observed 

changes in these measures can reflect a range of factors. 

Healthy life expectancy can be brought about by changes in 

risk-related health behaviors (because of technological or 

medical advancement affecting the diagnosis, treatment, and 

progression of diseases) or because disability has been 

reduced (by better intrinsic health or because the extrinsic 

environment becomes more adapted to persons with 

functioning problems). Consequently, care and additional 

data are required to interpret the analyses underlying these 

statistics. 

Disability-Adjusted Life Years (DALYs)—The World 

Bank and World Health Organization have supported a 

project to develop methods to evaluate the distribution of 

scarce health resources in developing countries. As a result, 

there is now a growing interest in another approach to 

summary measures—Disability-Adjusted Life 

Years—DALYs (25–32). DALYs represent an alternative 

Figure 1.3. Health care and public health intervention opportunities

4 Summary Measures of Population Health
approach to summary measure construction that links 

disease, disability, and death. This approach estimates years 

of life lost from deaths which occur before some 

theoretically achievable age (e.g., international reports use 80 

years for men and 82.5 years for women) and attributing this 

loss to death rates. Next, years lost to nonfatal diseases are 

calculated by linking the incidence of diseases to disability 

levels and length of time with disability. DALYs differ from 

other measures described because they reflect years lost to 

ill-health instead of years lived with ill-health; another 

difference is that they link two major dimensions of health: 

disease and disability. 

DALYs also incorporate weights to reflect the severity of 

disability, and, because of the emphasis on health policy in 

the international applications, DALYs incorporate an 

additional economic approach to weighting years of life. 

This approach gives current years of life higher weights than 

future years of life, and life in the productive years or 

working ages is given higher weights than life in 

nonproductive years. These weighting schemes dramatically 

affect how years of healthy life are calculated for people of 

different ages as well as for people with different 

disabilities. 

In contrast to the cross-sectional Sullivan approach to 

estimating healthy life expectancy, DALYs have been 

developed as an incidence-based measure, that is, one that is 

based on the transition into disease or disability. Incidence is 

a flow measure, whereas prevalence is a stock measure. 

Researchers have long recognized that incidence rates are 

theoretically preferable to prevalence data for indicating 

health change: incidence rates reflect only recent events, 

while prevalence data reflect events that occurred earlier in a 

person’s lifetime. Incidence rates, however, require 

longitudinal data from large samples, and they usually are 

not available for most conditions or for nationally 

representative populations of most ages. 

Because the incidence data required for input to the 

DALYs do not exist, they have been estimated from 

whatever epidemiological information can be pieced 

together. For example, community-based surveys like the 

Framingham Study provide a source of information on 

disease onset. Disability levels related to disease onset were 

then determined using ‘‘expert’’ opinions. Weights for the 

value of life spent in disease-disability levels were then 

developed in a series of workshops with a variety of 

‘‘experts.’’ 

1.3 Potential Summary Measures Suggested

for Healthy People 2010

After discussing both general approaches to estimating 

summary measures and a large number of specific 

approaches to these measures, workshop attendees were 

asked to recommend summary measures for consideration 

for the Healthy People 2010, keeping data availability in 

mind. The most important recommendation resulting from 

this meeting was that: 

No single measure can adequately incorporate all aspects

of health and mortality. A set of summary measures

including both mortality and various aspects of morbidity

or health that can be calculated from existing or collectable data should be proposed for Healthy People 2010.

Using a set of measures rather than a single measure will 

make it possible to trace a variety of healthy life dimensions 

and to note differences in various aspects of health. It will 

also be possible to identify progress in some domains of 

health that have led to what appears to be deterioration in 

other aspects of health. For instance, progress made in 

prolonging the lives of persons with AIDS (brought about 

by a variety of pharmaceutical developments) may 

lengthen average life, increase the number of years lived 

with AIDS, lead to an increase in the number of people 

with AIDS in the population, and change the health status 

of those living with AIDS. Using a set of summary 

measures instead of a single measure will help clarify the 

meaning of change in the most general measures and 

disentangle either programmatic or medical influences; 

thus, progress toward reaching Healthy People 2010 goals 

can be better monitored. 

Although the two types of measures, HLE and DALYs,

were discussed, HLE measures were recommended for

Healthy People 2010. In addition, all suggested measures

were based on cross-sectional data. Further investigation

of the properties of incidence-based measures needs to be

completed before using them for health monitoring.

The set of measures recommended for monitoring the 

first goal of Healthy People 2010 include the following: 

Years of healthy life defined as life without disability:

This represents one of the most general summary measures 

as disability is a late stage in figure 1.1 and reflects 

population health states of all the prior health dimensions. 

Because disability refers to the inability to perform expected 

tasks, this definition of years of healthy life may reflect the 

overall impact of health problems. Healthy life can be 

defined as life lived without any health limitation that 

prevents normal activity. Life with disability can be 

subdivided into ‘‘life with severe and moderate disability’’ as 

well as ‘‘life with limitation in personal care, work, or 

school.’’ This type of measure can clearly define and 

characterize a healthy year of life, that is, a year without 

disability. 

Years of Healthy Life (as used for Healthy People 2000): 

The summary measure that was developed for Healthy

People 2000 represents multiple dimensions of health (33). It 

includes both disability and the individual’s assessment of all 

aspects of health. It should continue to be included among 

the Healthy People 2010 measures for comparison over time 

and with other measures. This measure uses a weighting 

scheme; that is, it includes severity of health problems in the 

calculation. It is more difficult to define the meaning of a 

year of healthy life with this measure because it incorporates 

multiple aspects of health. 

Summary Measures of Population Health 5
In addition to the two measures above, more narrowly 

defined measures of health also can be the basis of summary 

measures that are comparable over time and across 

population subgroups. Measures based on health-related 

behaviors, functioning, disease, and self-assessed health, 

coupled with mortality, were suggested. These additional 

measures have the potential to clarify which dimensions of 

health are changing and thus can be linked to programs and 

policies that might be causing health change. Such measures 

can include: 

Years of life without functioning problems: Summary 

measures based on functioning could be defined by ability to 

perform certain functions, such as walking, lifting, picking 

up objects, etc. For this purpose, both physical and mental 

functioning should be considered. 

Years of life without specified diseases: Summary 

measures could include years without a variety of major 

diseases and conditions; the converse, years with conditions, 

could also be estimated. 

Years of life in excellent or very good health:

Self-perceived health can be used alone in a summary 

measure to reflect change in peoples’ assessment of their 

health. Length of life in excellent health or in very good or 

excellent health can be a summary measure as can years 

spent in poor health or fair or poor health. 

Years of life lived with good health behavior: This 

measure can serve as a summary measure of years spent 

with risk factors for some of the other health outcomes. For 

instance, the average years with no risky health behavior 

(e.g., smoking, drinking, obesity, and no health care) can be 

estimated. Estimates can be based on single behaviors or 

groups of behaviors. Years without any risk behaviors can 

also be estimated. 

All of the proposed summary measures can be 

constructed with available data and should be available for 

major subgroups of the population. Some can be constructed 

for sub-national geographical areas such as States. All the 

recommended measures can be used to reflect progress 

toward both goals of increasing the quality and years of 

healthy life and decreasing health disparities as they can be 

estimated for gender and major racial and ethnic groups. 

1.4 Availability of Data for Estimating the

Proposed Measures

The suggested measures can be estimated for a number 

of years in the 1990s using available data from NHIS. 

However, the 1997 redesign of the NHIS survey will make it 

difficult to have a lengthy series for some of the measures. 

For subgroups of the population, it may be necessary to 

combine years to produce reliable estimates for some age, 

racial, and ethnic groups. One necessary component of the 

measures is the annual life table for the population along 

with the life tables for the subgroups of interest. Life tables 

by socioeconomic status (SES) are not regularly produced 

but could be produced using data such as the mortality 

followup for NHIS. Consideration should be given to the 

reliability of annual changes of mortality as well as health 

data. 

It will be important to apply these measures across 

various geographic and political levels, including States and 

municipalities. Many of these measures can be estimated for 

States. The possibility of estimating these statistics for 

smaller geographic areas needs to be investigated. Estimates 

for the institutional population need to be included in the 

summary measures. Estimates of the size and composition of 

the relevant institutional population are difficult to obtain but 

need to be part of the measures if they are to describe the 

entire population. Issues of data availability for the 

institutional population need to be addressed. 

This report presents the results of research conducted to 

investigate various issues of immediate interest for 

monitoring progress toward the Healthy People 2010 goals. 

Healthy life expectancies were estimated using different 

definitions of health. Selected estimates for various 

population subgroups are presented in chapter 3. All of the 

estimates presented in the chapter are calculated based on 

health data from NHIS. Since NHIS does not include the 

institutional population, the estimates in chapter 3 might be 

at variance with estimates made including the institutional 

population. The possible impact of not including the 

institutional population in estimating healthy life 

expectancies is discussed in chapter 5. Two other important 

points should be kept in mind in reading the estimated 

healthy life expectancies in this report. First, the expected 

years of healthy life presented in this report are different 

from the Years of Healthy Life (YHL) used in Healthy

People 2000 in both the interpretation of the results as well 

as in the method of calculation. (The method of calculation 

and interpretation of YHL used in Healthy People 2000 is 

described in Statistical Notes no 7 (33).) Second, the survey 

instruments and method of data collection of NHIS were 

revised in 1997. However, since all NHIS data used in this 

report are from surveys conducted prior to 1997, the 1997 

revision of NHIS does not affect the results of this report. 

Data used for this report are mainly from the NCHS and 

the U.S. Census Bureau. The method that is widely used for 

calculating healthy life expectation using cross-section data 

is explained succinctly following this introductory chapter. 

Expected years of healthy life under various definitions of 

health and variation of results by measure are discussed in 

chapter 3. Chapter 4 summarizes trends in years free of 

activity limitation for the period 1985–95. In addition to 

estimating healthy life expectancy under different attributes 

of health and looking at trends in limitation-free life, the 

report includes a test of the effect of including data from 

different sources on estimated healthy or limitation-free 

years. An illustration of this impact analysis is presented in 

chapter 5. The overall summary of the report and 

recommendations for the longer term endeavor of solving 

problems of data constraints and the construction of more 

comprehensive models of summary measures of health are 

highlighted in the last chapter. 

6 Summary Measures of Population Health
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Health 54 1063–70. 1964. 

2.Sullivan DF. Conceptual problems in developing an index of 

health. Vital and Health Statistics, 2(17): National Center for 

Health Statistics, Washington, D.C. 1966. 

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HSMHS Health Reports 86:347–54. 1971a. 

4.Sullivan DF. Disability components for an index of health. 

Vital and Health Statistics. 2(42) National Center for Health 

Statistics, Rockville, Maryland. 1971b. 

5.Fries JF. Aging, natural death, and the compression of 

morbidity. N Engl J Med 303(3):130–5. 1980. 

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Q 67(2):208–32. 1989. 

7.Manton KG. Changing concepts of morbidity and mortality in 

the elderly population. Milbank Q: Health Society 60(2): 

183–224. 1982. 

8.Gruenberg EM. The failure of success. Milbank Q: Health 

Society 55(1):3–24. 1997. 

9.U.S. Department of Health and Human Services, Office of 

Disease Prevention and Health Promotion. Healthy people 

2000. Washington, D.C. 1991. 

10.U.S. Department of Health and Human Services. Healthy 

people 2010. 2nd ed. With understanding and improving 

health and objectives for improving health. 2 vols. 

Washington, D.C.: U.S. Government Printing Office. 2000. 

11. Field MJ, Gold MR. (eds). Summarizing population health: 

Direction for the development and application of population 

metrics. Institute of Medicine, National Academy Press, 

Washington, D.C. 1998. 

12.U.S. Department of Health and Human Services. Leading 

indicators for healthy people 2010: A report from the HHS 

working group on sentinel objectives. U.S. Government 

Printing Office. Washington, D.C. 1998. 

13.Crimmins E, Hayward MD, Saito Y. Changing mortality and 

morbidity rates and the health status and life expectancy of 

the older U.S. population. Demography 31:159–75. 1994. 

14.Verbrugge L. Disability in late life. In Aging and quality of 

life. Abeles R, Gift H, and Ory M. (eds). pp. 79–98. Springer, 

New York. 1994. 

15.World Health Organization. International classification of 

impairment, disabilities and handicaps: A manual of 

classification relating to the consequences of disease. Geneva. 

1980. 

16.Verbrugge LM, Jette AM. The disablement process. Soc Sci 

Med 38(1):1–14. 1994. 

17.Crimmins E, Hayward MD, Saito Y. Differentials in active life 

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Gerontol B Psychol Sci Soc Sci 51(B3):S111–S120. 1996. 

18.Brandt EN, Pope AM. Eds. Enabling America: Assessing the 

role of rehabilitation science and engineering. Division of 

Health Sciences Policy, Institute of Medicine, National 

Academy Press, Washington, D.C. 1997. 

19.Mathers E. Health expectancies: an overview and critical 

appraisal. In Summary measures of population health: 

Concepts, ethics, measurement and applications. C. J. L. 

Murray, et al. (eds). pp. 177–204. WHO, Geneva. 2002. 

20.Jagger C. Health expectancy calculation by the Sullivan 

Method: A practical guide. Euro-REVES. 1997. 

21.Crimmins E, Saito Y, Ingegneri D. Changes in life expectancy 

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Population and Development Review 15:235–67. 1989. 

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23.Hayward MD, Heron M. Racial inequality in active life 

among adult Americans. Demography 36(1):77–91. 1999. 

24.Fryback D. Methodological issues in measuring health status 

and health-related quality of life for population health 

measures: A brief overview of the ‘‘HALY’’ Family of 

Measures. In Summarizing population health: Directions for 

the development and application of population metrics. Field 

MJ and Gold MR. (eds). National Academy Press, 

Washington, D.C. 1998. 

25.Murray C, Lopez A. Global and regional cause-of-death 

patterns in 1990. Bulletin of the World Health Organization 

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Statistical Notes, no 7. Hyattsville, Maryland: National Center 

for Health Statistics. 1995. 

Summary Measures of Population Health 7
2. Methods for Calculating Healthy Life Expectancy

2.1 Introduction

Healthy life expectancies are calculated using models 

that incorporate measures of mortality and morbidity as 

schematically presented in figure 2.1 (1). 

Age-specific death rates account for the mortality 

component. Age-specific rates of population morbidity, 

disability, or some other aspect of health account for the 

morbidity component. These two components are combined 

using a mathematical function that transforms the two sets of 

partial measures into a single composite measure using a life 

table methodology. Figure 2.2 displays the framework of this 

calculation, including the type of data needed and the 

techniques used to estimate the two components of the 

measure at the national level. 

National mortality data are obtained from the National 

Vital Statistics System of NCHS. Mortality data are collected 

by each State and the District of Columbia and compiled at 

the national level by NCHS. Mid-year population estimates 

are from the U.S. Census Bureau. 

Health data can come from a number of different 

sources, depending on the type of health measure and the 

population being considered. The range of items that could 

be used to characterize health is illustrated by a ‘‘health state 

classification system’’ developed by Boyle and Torrance 

(displayed, in part, in figure 2.3) (2). The classification 

system of Boyle and Torrance conceptualizes the 

interrelationship of health attributes as hierarchal, based on 

breadth and on coverage of different aspects of health. For 

example, physical function, which is one of the primary 

health attributes, has four secondary attributes, one of which 

is self-care. Self-care may, in turn, be disaggregated into 

more specific health attributes, shown as the third level of 

classification in figure 2.3. 

The estimation of healthy life expectancy begins with the 

calculation of life table values followed by the calculation of 

age-specific prevalence rates of being healthy and not being 

healthy. The formulas needed to calculate the life table 

values for an abridged life table are summarized in section 

2.2.1. To calculate the age-specific prevalence rates of being 

healthy, first calculate the rates of reporting ‘‘fair or poor’’ 

health (nπx). The rates of being healthy, that is, reporting 

‘‘good or better’’ health is then (1–nπx). Then for each age 

interval (x, x+n), the rates of being healthy (1–nπx) are 

multiplied by the total number of years lived within the 

same age interval (nLx). This calculation provides an 

estimate of the total number of years a group of persons are 

expected to live in a healthy state during the interval. The 

age interval (n, n+x) equals 1 for single-year age groups; it 

equals 5 if data used are in 5-year age groups and 10 for 

10-year age groups. The model used to estimate HLE (i.e., 

the expected number of years in good or better health) is 

summarized in section 2.2.2. 

Healthy life expectancy could be estimated using a 

variety of health attributes. For instance, the model may be 

used to estimate disability-free life expectancy or life 

without activity limitation, also referred to as expected years 

of active life. Regardless of the health attribute chosen, the 

model uses two separate and independent partial health 

measures: (1–nπx) for the morbidity component and lx and 

nLx for the mortality component. 

2.2 The Life Table Technique

The life table, also known as the mortality table, is used 

to present the ‘‘most complete statistical description’’ of 

mortality (3). The life table also has been an important tool 

for demographers who are interested in estimating the 

probability of marriage and remarriage, widowhood, 

orphanhood, and in migration and population projections (4). 

A brief summary of the method commonly used to estimate 

life table values, healthy life expectancy, and the standard 

errors of HLE will be presented in the remaining parts of 

this chapter. For a more detailed explanation of the method 

with illustrative examples and the associated sensitivity 

analysis, refer to Healthy People 2010 Statistical Notes, No. 

21 and No. 22 (5,6). 

2.2.1 Estimating the average expectation of life

The objective of the life table is to calculate the expected 

number of years lived, if a group of people, currently age x, 

lived the rest of their lives experiencing all the age-specific 

mortality rates observed for the population at a specific time. 

The estimation of life table values, such as the expectation 

of life, begins with the computation of age-specific death 

rates. The two sets of data required to construct a life table 

are the mid-year population and the number of deaths in that 

year. These data could be analyzed in single years of age or 

5- or 10-year age groups. (Methods for constructing a 

complete annual life table are discussed in NCHS Vital and 

Health Statistics, no. 129.) (7) The process could be applied 

to the construction of a life table for national, State, or local 

populations. 

The estimation begins with counts for the population nPx

and deaths nDx for each age group. Population counts are 

based on mid-year estimates. Deaths are for the entire year. 

These are used to compute the average death rate of each 

age group for the year (nMx, where n, the number of years in 

the age group, can be 5 or 10 years), as 

nMx = nDx / nPx . [1] 

8 Methods for Calculating Healthy Life Expectancy
The computed age-specific death rates need to be checked 

for stability. Age-specific death rates are considered to be 

stable if they are based on 20 or more deaths. Rates based 

on fewer than 20 deaths have a ‘‘relative standard error of 

23 percent or more and therefore are considered highly 

variable.’’ (8) 

The conditional probability of dying within a given age 

group nqx is the proportion of people in the age group alive 

at the beginning of the age interval who die before reaching 

the next age group. Whereas nMx is an annual death rate, nqx

is a conditional probability of dying. This probability is 

estimated as: 

nqx = [n nMx]/[1+ n(1–ax) nMx], [2] 

where ax is the average proportion of years lived by those 

who died in this age interval. The conditional probability of 

dying is assumed to be 1.0 for the open, oldest age interval. 

In the example presented here, n is 5 years, so the 

probability becomes: 

5qx = [55Mx] / [1 + 5(1–ax) 5Mx]. 

The values for ax are constants derived from the complete 

life tables (9). For single-year life table value calculations, ax

may be assumed to be 1⁄2. 

Having calculated the conditional probability of dying, 

one can now calculate the probability of surviving to an 

exact age marking the beginning of an interval. In the life 

table, this is expressed as the number of persons surviving to 

an exact age (or the exact age at the beginning of an age 

interval when group data are used), starting with an assumed 

cohort population (l0) frequently expressed as 100,000 at 

birth. For any other age x, the number of survivors at that 

age lx can be calculated. Hence, the number alive at exact 

age x+n (lx+n) is calculated by multiplying the number of 

survivors at exact age x (lx) by the probability of surviving 

from age x to age x+n (1–nqx) or: 

lx+n = lx (1–nqx). [3] 

The total number of person-years lived for those people who 

were alive at the beginning of the age interval x to x+n is 

then the sum of the total number of years lived by 

individuals surviving to the end of the age interval plus the 

total number of years lived by those who died in the age 

interval. This becomes: 

nLx = n {lx+n + ax (lx – lx+n)} . [4] 

In the example presented here, n = 5 so, 

5Lx = 5{lx+5 + ax (lx – lx+5)} . 

The person-years remaining for the population, that is, 

Tx, is simply the total of all the person-years for age x and 

all subsequent age groups, or: 

Tx = Σ nLi for i = x, x+n, ... , oldest age group. [5] 

The average expected years per person is then the total 

person-years divided by the number of persons surviving to 

the beginning of the age interval x, or: 

ex = Tx / lx . [6] 

2.2.2 Estimating healthy life expectancy

The life table technique is a powerful tool for estimating 

the remaining years of life that a group of persons would 

Figure 2.1. A schematic presentation of the model

SOURCE: Adapted from a model by the Institute of Medicine, National Academy of Sciences, 1998.

Methods for Calculating Healthy Life Expectancy 9
Figure 2.2. A schematic framework for estimating healthy life expectancy at the national level using respondent-assessed health status

as an example

Figure 2.3. Example of attributes for health classification system

SOURCE: Boyle and Torrance. ‘‘Developing Multi-attribute Health Indexes.’’ Medical Care, 1984.

10 Methods for Calculating Healthy Life Expectancy
expect to live once they had reached a certain age.

Regardless of their age, the remaining years of life might be

lived in good health or in less optimal health states or some

combination of both. The traditional life table technique does

not distinguish between remaining healthy years and

unhealthy years. Additional data are needed to disaggregate

the total number of years into expected years of healthy and

of unhealthy life.

The total number of expected years of life are partitioned

into healthy and unhealthy years using health data

(figure 2.2). In general, health data, collected through health

surveys or from clinical observations, are used to estimate

the prevalence of different health states. The population is

then partitioned into proportions that are experiencing

varying states of health. The partition may be as simple as

dividing the population into those who are healthy and those

who are unhealthy. Or, the population may be partitioned

into more than two population subgroups, according to

varying degrees of health, using multidimensional scaling to

describe health states.

To calculate HLE, the population of each age interval in

the life table is partitioned into the proportion experiencing

an unhealthy condition (5πx) and those that are considered

‘‘healthy’’ (1–nπx). Since nLx is the total number of

person-years lived for the population in age interval x to x+n

(equation 5), the proportion of these years lived in a healthy

state (nLx) is then:

′ xLx = (1–nπx) nLx . [7]

One of the following two equations can be used to

determine HLE:

w 1 ′ ′ e x = lx∑ nLx .

i =x [8]

or

w 1 ′ e x = lx∑ (1–nπi

) nLi

i =x [9]

where

′ ex is HLE at age x, or the number of remaining years

of healthy life for persons who have reached age x;

lx is the number of survivors at age x;

(1–nπx) represents the age-specific rate of being healthy;

nLx is the total number of years lived by a cohort in the

age interval (x, x+n); and

w is the oldest age category.

′ The expected years of unhealthy life is ex – ex . However,

if multiple states of health status are described, the

prevalence for each of those states for each age interval

must be calculated. Equations similar to [8] and [9] are used

to estimate separately the expected years of life in those

health states.

2.2.3 Standard errors of healthy life expectancy

The estimates for age-specific prevalence of healthy and

unhealthy states are derived from surveys or samples.

Consequently, these estimates have associated sampling

error. Calculating the standard error of the resulting

estimated HLE is especially important when comparing

population subgroups. This section discusses the method of

estimating the standard errors of HLE, with and without

information on the survey sample design. Standard errors for

the other life table values can be calculated separately when

needed. See Chiang and Keyfitz for details (10,11).

Each age-specific value of the prevalence of the

population experiencing healthy life, (1–nπx), is an estimated

proportion with an associated variance and standard error.

The variances of these proportions and their standard errors

may be estimated using routine statistical methods.

Consequently, the variance (S2

) is given by the binomial

variance of:

S2(nπx)=[nπx (1–nπx)] / nNx , [10]

where nNx is the number of persons in the age interval

(x, x+n) of the sample from which the prevalence rates were

computed.

The variances of the prevalence rates from equation 10

′ can be used to estimate the overall variance of ex using the

following formula:

w 1 ′ VAR(ex) = 2∑ [nLi

2 S2

(1–nπi)] . lx i =x [11]

Illustrative applications of the variance of HLE using 1995

U.S. population data are presented in Healthy People 2010

Statistical Note No. 21 (5).

References

1. Field MJ. Gold MR. (eds). Summarizing population health:

Direction for the development and application of population

metrics. Institute of Medicine. Washington, D.C.: National

Academy Press. 1998.

2. Boyle MH, Torrance GW. Developing multi-attribute health

indexes. Med Care 22(11):1045–57. 1984.

3. Pressat R. Demographic analysis. New York: Aldine

Publishing. 1961.

4. Spiegelman M. The versatility of the life table. Am J Public

Health 47:297–304. 1957.

5. Molla MT, Wagener DK, Madans JH. Summary measures of

population health: Methods for calculating healthy life

expectancy. Statistical Notes, no 21. Hyattsville, Maryland:

National Center for Health Statistics. August 2001.

6. Wagener DK, Molla MT, Crimmins EM, Pamuk E, Madans

JH. Summary measures of population health: Addressing the

first goal of Healthy People 2010, improving health

expectancy. Statistical Notes, no 22. Hyattsville, Maryland:

National Center for Health Statistics. September 2001.

Methods for Calculating Healthy Life Expectancy 11
7. Anderson RN. Methods for constructing complete annual U.S.

life tables. National Center for Health Statistics. Vital Health

Stat 2(129). 1999.

8. National Center for Health Statistics. Vital statistics of the

United States, 1992, vol II, mortality, part A. Washington:

Public Health Service. 1996.

9. Sirken MG. Comparison of two methods of constructing

abridged life tables by reference to a ‘‘standard’’ table.

National Center for Health Statistics. Vital Health Stat 2(4).

1966.

10. Chiang CL. A stochastic study of the life table and its

application: II. Sample variance of the observed expectation

of life and other biometric functions. Hum Biol 32:221–38.

1960.

11. Keyfitz N. Introduction to the mathematics of population with

revisions. Cambridge, MA: Addison Wesley. 1968.

12 Methods for Calculating Healthy Life Expectancy
3. Expected Years of Healthy Life Under Various Definitions of Health 

3.1 Introduction 

No single definition of the component of healthy life

expectancy measures the nonfatal health outcome.

Prevalence or incidence of health-related occurrences are

numerous and measure different aspects of health. These

include self-rated health or measures of work, activity, or

functional limitations. They could also be observed rates or

probabilities of the occurrence of bad physical or mental

health, acute or chronic conditions, health-related behaviors,

or even health service utilization. In this chapter, the

practical application of the composite measure is illustrated

by combining various nonfatal health outcome measures

with life table values; these combinations are used to

estimate a variety of healthy life measures such as expected

life in good or better health, free of activity limitation, or

without needing help in ADL or IADL.

Healthy life expectancy will be estimated first as

expected years without health-related limitation. That is, the

prevalence of activity, work, and functional limitations will

be used as the nonfatal measure. Second, healthy life

expectancy from the perspective of diseases or chronic

conditions will be discussed using the prevalence of chronic

arthritis, heart diseases, hypertension, and diabetes.

Prevalence of overweight and obesity among adults will be

used to discuss healthy life expectancy as a measure of

health-related behavior.

Healthy life expectancies are estimated by 5-year age

group and sex. Estimates are also presented by race

whenever data by race are considered reliable. Data from

various sources are used for the estimates. Life expectancies

by 5-year age group, sex, and race are estimated using data

from NCHS and the U.S. Census Bureau as described in

chapter 2. Prevalence rates of the various health states are

calculated from the person and condition files of NHIS for

the years 1985–96.

3.2 Expected Years of Healthy Life for Males 

and Females 

As numerous studies have shown that healthy life

expectancies vary considerably both by age and sex (1–4),

disparities in healthy life expectancies will be discussed for

subgroups defined by these factors. Measures used for the

discussion include expected years in good or better health,

years in excellent health, years without activity limitation,

years without work limitation, years without limitation in

ADL or IADL, and years without disease or chronic

conditions.

3.2.1 Expected years in good or better health 

Expected years of life is first measured using ‘‘expected

years in good or better health.’’ First, respondents who stated

that they were in good, very good, or excellent health were

classified as ‘‘persons in good or better health’’; respondents

who assessed their health as fair or poor were considered

‘‘persons in poor health.’’ Expected years of healthy life can

also be estimated using ‘‘expected years in excellent health.’’

To estimate expected years in excellent health, respondents

were classified depending on whether their self-assessed

health was excellent. Figure 3.1 presents the distribution of

those reporting good or better health by 5-year age group

and sex. The percentage of those who were in good or better

health declines with age, slowly for younger adults, but

relatively faster for older adults. The estimated years in good

or better health and in excellent health for selected ages by

sex are presented also in table 3.1.

The table indicates that in 1995, a newborn baby would

expect to live 75.8 years (72.8 years for males and 78.8

years for females). Of this total expected life span, 66.5

years (87.7 percent) were expected to be in good or better

health, whereas only 26.4 years (34.8 percent) were expected

to be in excellent health. Expected years of healthy life,

measured in years as well as a percentage of total life

expectancy, varies by age. As one gets older, years in good

or better health decrease in both absolute and relative terms.

In 1995, for example, a person at age 20 would expect to

spend 84.3 percent of his or her future life in good or better

health and only about 29.0 percent in excellent health. At

age 65, these percentages declined to 71.0 percent and 14.9,

respectively.

Expected years in good or better health and in excellent

health also varied by sex. Females could expect to live more

years in good or better health than their male counterparts.

On the other hand, males could expect a relatively higher

proportion of their future life in good or better health at the

younger ages whereas females seem slightly better off after

age 65 (figure 3.2). When healthy life is measured in terms

of expected years in excellent health, males at younger ages

would expect to spend more years and a higher proportion

of their lives in excellent health than females. The opposite

was true after age 75. The table also indicates that as the

population ages, the difference in healthy life between males

and females declines slightly, especially when healthy life is

measured in years rather than as a percent of life expectancy.

The difference between expected years in good or better

health for males and females is statistically significant

(p<0.05) except at age 85.

Expected Years of Healthy Life Under Various Definitions of Health 13
Figure 3.1. Percentage of persons reporting good or better health, by age and sex: United States, 1995

3.2.2 Expected years without activity limitation 

In the 1995 NHIS, respondents were asked about activity

limitation. Respondents were categorized into one of the

following groups: not limited in any way; unable to perform

their major activity; limited either in kind/amount of their

major activity; and limited in activities other than the one

identified as the major activity. Respondents with unknown

activity limitation status were assumed to be not limited (5).

Expected years of healthy life defined as disability-free life

expectancy (DFLE) were estimated based on the prevalence

of major activity limitation only and on any type of activity

limitation. The distribution of those free of any activity

limitation by 5-year age group and sex is presented in

figure 3.3. The figure indicates that activity limitation is a

function of age. The percentage of males and females

without any activity limitation declines with age at a slower

rate at the younger ages and a relatively faster rate at the

older ages.

The expected years without major activity limitation and

years without any limitation for selected ages by sex is

presented in table 3.2 and figure 3.4. On average, individuals

of all ages could expect to spend more than 4 of every 5

years without limitation in their major activity. A baby born

in 1995 would be expected to spend more than 94 percent

(94.1 for males and 94.7 percent for females) of his or her

total life expectancy without limitation in major activity. At

age 65, this percentage dropped only by about 5 percentage

points to 89.1 percent (88.6 for males and 89.5 percent for

females). On the other hand, when the broader definition of

the measure ‘‘any activity limitation’’ is used, the percentage

of life expected to be without limitation declined from 94.4

to 82.5 percent at birth (from 94.1 to 83.2 percent for males

and from 94.7 to 81.9 percent for females) and from 89.1 to

61.3 percent at age 65.

Females could expect to live more years without major

or any other type of activity limitation. The difference

between males and females in expected years without major

Figure 3.2. Percentage of expected life in good or better health at

birth, 20, and 65 years of age, by sex: United States, 1995

14 Expected Years of Healthy Life Under Various Definitions of Health
Figure 3.3. Percentage free of activity limitation, by age and sex: United States, 1995

activity limitation is statistically significant (p<0.05) except

at age 85; likewise, the difference between males and

females in expected years without any activity limitation is

statistically significant, except at age 80. On the other hand,

the results of the comparison of activity limitations as a

percent of total life expectancy by gender are not clear-cut.

Females could expect to have a larger percentage of their

future life free of major activity limitation at almost every

age except for the oldest. On the other hand, controlling for

age, males could expect a larger part of their life to be free

of any activity limitation.

3.2.3 Expected years without work limitation 

In the 1995 NHIS, activity limitation status can also be

measured based on ‘‘ability to work’’ for adults between 18

and 69 years of age. Based on their responses, respondents

were classified as ‘‘unable to work,’’ ‘‘limited in

kind/amount of work,’’ and ‘‘with no work limitation.’’

Adults between the ages of 18 and 69 with unknown work

limitation status were considered ‘‘not limited.’’ The

proportion able to work and without any work limitation was

used to estimate expected years able to work and expected

years without any work limitation. The results for selected

ages by sex are presented in table 3.3.

On average, in 1995 a person would expect to live 42.8

years between age 20 and 69. For 39 of these expected years

of life (91.2 percent), the person would be able to work, and

36.6 of those years (85.5 percent) would be without any type

of work limitation. Males would expect to live an average of

41.2 years between the ages of 20 and 69. For 37.5 years

(91 percent), an adult male would expect to be able to work;

the same adult male would spend 35.1 of those years

(85.2 percent) without any type of work limitation.

Between age 20 and 69, compared to adult males, adult

females would expect to spend more years and larger

percentage of their average expected years able to work and

without any type of work limitation. The table shows that,

on average, an adult female between ages 20 and 69

expected to live 44.6 years. For 40.8 of those years

(91.4 percent) they would expect to be able to work, and

they would expect to be free of any work limitation for 38.3

years. The number of years a person would expect to be able

to work and the expected number of years free of any work

limitation declined with age, but the years expressed as a

percentage of life expectancy remained fairly constant over

age for both males and females.

3.2.4 Expected years without functional dependency 

In the 1995 NHIS, respondents 65 years of age and over

were also asked whether or not they needed help from other

persons for their personal care or other routine needs

because of physical, mental, or emotional problems. Personal

care needs or ADL included bathing or showering; dressing;

eating; getting in and out of bed or chairs; using the toilet,

including getting to the toilet; and getting around inside the

home. Other routine needs or IADL included preparing own

Expected Years of Healthy Life Under Various Definitions of Health 15
Figure 3.4. Percentage of life expectancy free of any activity

limitation at birth, 20, and 65 years of age, by sex: United States,

food; shopping for personal items; managing money; using

the telephone; and doing heavy work around the house (5).

The recoded response categories were persons who need

the help of other persons to ‘‘perform personal care needs,’’

those who need the help of other persons ‘‘to perform other

routine needs,’’ and those who are ‘‘not limited in

performing personal or routine needs.’’ Those with unknown

limitation status were assumed to be not limited in

performing personal care or other routine needs. Figure 3.5

presents the percentage distribution of those who were able

to perform personal care needs or who were not limited in

other routine needs of daily living by 5-year age group and

sex. The distribution indicates that limitation in personal care

or other routine needs of daily living was a health problem

mostly associated with old age. Expected years without

functional dependency were calculated, and the results for

some selected ages by sex are presented in table 3.4.

According to the results of the 1995 NHIS data, those

who were younger than age 75 could expect to live more

than 90 percent of their remaining life without functional

dependency. A 75-year-old male would expect to live about

90.2 percent of his total expectation of life without

functional dependency. The percentage declined to only

88.1 percent at age 80. At age 75, on average, adult females

would expect to live nearly 88 percent of the remainder of

their lives free of functional dependency. On average, an

80-year-old female would expect to live 83.4 percent of her

life expectation free of functional dependency.

When years without limitation were measured in terms

of functional dependency due to limitations in ADL or other

routine needs (IADL), adults younger than 65 years of age

could expect to live more than 80 percent of their expected

lives free of limitation (more than 86.5 percent for males and

80.1 percent for female). At any given age, females would

expect to live more years without functional dependency

because of ADL or IADL limitation. The difference between

males and females in expected years without ADL or IADL

Figure 3.5. Percentage able to perform personal care needs or not limited in other routine needs, by age and sex: United States, 1995

16 Expected Years of Healthy Life Under Various Definitions of Health

1995
Figure 3.6. Percentage of life expectancy able to perform

personal care needs or not limited in other routine needs at 45,

65, and 75 years of age, by sex: United States, 1995

limitation is statistically significant (p <0.05) at all ages.

However, as a percent of life expectancy, males had more

functional dependency-free life. At age 65, for example,

males could expect to live 86.5 percent of their remaining

lives free of functional limitation because of limitation in

ADL or IADL. On the other hand, females of the same age

could expect to live 80.1 percent of their remaining life free

of functional dependency because of ADL or IADL

limitation (figure 3.6). This is consistent with other research

findings (6).

3.2.5 Expected years without diseases or chronic

conditions

Expected years of healthy life were also estimated based

on the prevalence of four selected chronic conditions:

arthritis, hypertension, heart disease, and diabetes. To

improve reliability of estimates, the prevalence rates were

estimated using 3 years of NHIS data, 1994–96. Age-specific

prevalence rates for males and females between 30 and 84

years of age are presented in table A. The estimates are

assumed to represent the midyear of the 3-year interval,

1995. Expected years without each of the four chronic

conditions are estimated for persons 30 years of age and

over; the results are presented in tables 3.6 and 3.7.

In 1995, a 30-year-old could expect to live another 47.5

years of which 34.7 years (73 percent) were expected to be

free of chronic arthritis. On the other hand, a person aged 65

years could expect to live 17.5 more years, of which only

8.8 (50.2 percent) years were expected to be free of chronic

arthritis. By age 75, expectation of life would drop to about

11 years and expected years free of chronic arthritis to about

5 years (about 46 percent of life expectancy).

Though females could expect to live longer, at every age

males could expect to live more chronic arthritis-free years

than females of the same age both in terms of number of

years and as a proportion of their life expectancies. The

difference between males and females in expected years free

of chronic arthritis is statistically significant (p <0.05) at all

ages. At age 30 for example, females could expect to live

50.1 years and males to live only 44. 9 years. But at the

same age, females expected to live only 34 years (68 percent

of their life expectancy) free of chronic arthritis while males

of the same age could expect to live 35.4 years (nearly

79 percent of their life expectancy) free of chronic arthritis

(table 3.5). At age 65, females could expect to live less than

half (44.8 percent) of their remaining years free of chronic

arthritis, while males 65 years of age expected to live

58.1 percent of their remaining years free of chronic arthritis

(figure 3.7).

Table A also shows that, compared to years free of

chronic arthritis, both male and female adults 30 years old

and over could expect to live more years free of chronic

heart diseases. A 30-year-old male could expect to live 37.1

years of his remaining 44.9 years free of chronic heart

diseases. A 30-year-old female, on the other hand, could

expect to live 42.7 years of the 50.1 years of her future life

free of chronic heart diseases. In terms of percentages of

expectation of life, while a 30-year-old male on average

could expect to live 82.8 percent of his future years free of

chronic heart diseases, a female of the same age could

expect to live 85.3 percent of her remaining life free of

chronic heart diseases (figure 3.8).

On the other hand, a 65-year-old male could expect to

live 15.9 years, of which 10.2 years would be free of

chronic heart diseases. In other words, 64.5 percent of the

Table A. Rates per thousand with chronic condition, by type of condition and sex at selected ages: United States,

1994–96

Diabetes Arthritis Heart diseases Hypertension

Age Male Female Male Female Male Female Male Female

Per 1,000 population

30–34 .............. 6.0 10.7 39.3 47.0 24.9 36.4 35.5 40.5

40–44 .............. 17.7 24.5 80.0 121.8 49.6 60.4 109.8 106.5

50–54 .............. 47.6 53.3 158.1 290.9 109.4 88.6 207.7 211.4

60–64 .............. 96.3 108.5 297.3 430.3 276.4 104.2 316.7 305.0

70–74 .............. 123.6 116.3 455.2 487.6 340.1 247.0 343.8 440.8

80–84 .............. 111.5 76.9 502.8 600.6 414.7 297.7 294.7 374.2

SOURCE: National Center for Health Statistics. National Health Interview Survey, 1994–96.

Expected Years of Healthy Life Under Various Definitions of Health 17
Figure 3.7. Percentage of life expectancy free of chronic arthritis

at 30, 65, and 75 years of age, by sex: United States, 1994–96

life expectancy of a 65-year-old male would be free of

chronic heart diseases. Alternatively, a 65-year-old female

could expect to live 18.8 more years. Of her total life

expectancy at this age, 13.6 years (or 72.3 percent) would be

free of chronic heart disease. Compared to adult males of the

same age, adult females could expect to live a larger

proportion of their future lives free of chronic heart diseases.

The difference between males and females in expected years

free of chronic heart disease is statistically significant

(p <0.05), except at age 85.

The number of years that adults could expect to live free

of chronic hypertension at selected ages is presented in

table 3.6. The table also presents the expected years adults

could expect to live without chronic diabetes. In 1995, a

30-year-old adult could expect to live for another 47.5 years,

of which 36.8 years (77.4 percent) would be free of chronic

hypertension. By age 65, total life expectancy would decline

Figure 3.8. Percentage of life expectancy free of chronic heart

disease at 30, 65, and 75 years of age, by sex: United States,

1994–96

to 17.5 years, and the percentage of life free of chronic

hypertension would also go down to about 62 percent.

Based on the 1995 mortality schedule and the 1994–96

age-sex-specific prevalence of chronic hypertension, a

30-year-old male, on average, could expect to live about

35.7 years (79.5 percent of his life expectancy) free of

chronic hypertension. At age 65, the average expected years

free of chronic hypertension would drop to 10.8 (68 percent

of life expectancy). Compared to males, females could

expect to live more years without chronic hypertension at

age 30, but by age 65, gender difference in the expected

years without chronic hypertension has almost disappeared.

However, at both the younger and older ages, the

percentages of remaining life free of chronic hypertension

were greater for males than for females (figure 3.9).

The table also shows that at almost all ages, adults 30

years of age or older could expect about 9 of every 10 of

their remaining years to be free of chronic diabetes. At age

30, almost 94 percent of life was expected to be chronic

diabetes-free, and this percentage declined by only about

5 percentage points to about 89 percent at age 65. Though

the gender difference in the percentage of life free of

diabetes was marginal, at each age, females could expect to

live more chronic diabetes-free years than males because of

the gender difference in total life expectancies. The

difference between males and females in expected years free

of chronic diabetes is statistically significant (p <0.05) at all

ages.

3.2.6 Expected years with body mass index (BMI)

less than 25 and years with BMI less than 30

Expected years of healthy life can also be estimated

using risk factors such as body mass index (BMI). BMI

relates the weight of individuals to their height. The specific

values of the BMI differentiates adults that are considered

overweight or obese from adults who are not considered

Figure 3.9. Percentage of life expectancy free of chronic

hypertension at 30, 65, and 75 years of age, by sex:

United States, 1994–96

18 Expected Years of Healthy Life Under Various Definitions of Health
Table B. Classification of overweight and obesity by body

mass index (BMI): Adults, 18 years of age and over

Weight Obesity class BMI

Underweight .......... Less than 18.5

Normal range ......... 18.5–24.9

Pre-obese ............ 25.0–29.9

Obesity ............. I 30.0–34.9

II 35.0–39.9

Extreme obesity ........ III Greater than or equal to 40

SOURCES: NIH (NHLBI), 1998; WHO, 2000.

overweight or obese. As is shown in table B, the National

Institutes of Health (NIH) and the World Health

Organization (WHO) classify an adult 18 years of age and

over as overweight if his/her BMI is 25 or over and as obese

if his/her BMI is greater than or equal to 30 (7,8). These

definitions were used to classify the adult population 18

years of age and over by BMI category using NHIS data for

the years 1994–96. The distribution of the population aged

20 and over that is not obese (BMI<30) by 5-year age group

and sex is presented in figure 3.10. The percentage of those

not obese declines until age 50 and then starts to rise again

after that age. Controlling for age, the percentage of males

and females who were not obese was similar for young

adults; however, after age 55, the difference between the

sexes is substantial, with males having a higher percentage

not obese.

The age-sex specific adult BMIs in combination with

1995 life table values were used to estimate the expected

years with BMI less than 25 and with BMI less than 30. The

results are presented in table B. Based on the mortality

schedules of 1995 and the average 1994–96 BMI, at age 20,

only half (49 percent) of the remaining life of a person was

expected to be spent with BMI less than 25 (i.e., within a

weight/height proportion accepted as ‘‘normal range’’ for a

healthy life).

Body Mass Index for different population subgroups was

calculated based on reported weights and heights. Compared

to BMIs calculated based on measured weights, BMIs

calculated based on reported weights tend to underestimate

overweight and obesity rates. BMIs calculated based on

measured weights (NHANES 1988–94) (9) were compared

to BMIs calculated based on reported weights (NHIS

1988–94). For the population aged 20 to 74 years old, BMIs

calculated based on reported weights underestimate both

overweight and obesity rates. Percent overweight was

underestimated by 3.1 percent for males (3.9 percent for

white, but overestimated by 2.2 percent for black) and

12.4 percent for females (12.9 percent for white and

9.2 percent for black). Percent obese is underestimated by

6.2 percent for males (6.6 percent for white and 3.8 percent

for black) and 11.1 percent for females (10.8 percent for

white and 11.8 percent for black). The underestimation of

overweight and obesity rates due to the use of reported

Figure 3.10. Percentage not obese, by age and sex: United States, 1994–96

NOTE: Not obese is defined as Body Mass Index (BMI) less than 30.

Expected Years of Healthy Life Under Various Definitions of Health 19
weight in the calculation of BMIs results in the overestimation of expected life with BMI less than 25 and with

BMI less than 30.

The percentage of adult life expectancy expected to be

spent with BMI less than 25 decreased continuously with

age for younger adults and then rose at the older ages. By

age 65, the percentage was 50.4, and by age 80, it was

63.6 percent. At each age, adult females expected to spend a

larger share of their future years with a BMI less than 25

than did adult males. At age 20, for example, while adult

females could expect to spend 57.2 percent of their average

life expectancy with a BMI less than 25; the share of

average life expectancy for adult males of the same age was

only 40 percent. At age 65, the percentage of life expectancy

to be spent with a BMI less than 25 rose to about 54 percent

for adult females but was expected to be only 50 percent for

adult males.

The table also shows that, on average, adults aged 20

years and over could expect to spend more than four fifths

of their lives without being obese (BMI less than 30); they

also could expect the percentage of remaining life expected

to be spent without being obese would rise with age, for

both adult males and females. At age 20, on average, adult

females could expect to spend 83.4 percent of their expected

lives with BMI less than 30, while adult males could expect

to spend 84 percent of their remaining lives with an average

BMI less than 30. At age 65, the average percentage of

remaining life expected to be spent with a BMI of less than

30 was 84.2 for females and 88 for males. Because of their

higher life expectancies compared to males of the same age,

adult females expected to spend more of their remaining

years with a BMI of less than 25 as well as a BMI of less

than 30. The difference between male and female expected

years with BMI less than 25 and BMI less than 30 is

significant (p<0.05) at all ages. Compared to males, adult

females at every age expected to spend a larger share of

their expected lives with a BMI less than 25; adult males

expected to spend a slightly larger percentage of their

remaining lives with a BMI less than 30 than females.

3.3 Expected Years of Healthy Life for the

White and Black Populations

Several studies have shown that the black population in

the United States has higher mortality than the white

population (10–12). Life expectancies by race indicate that

across all ages, white males have higher life expectancy

than black males, and white females have higher life

expectancy than black females. This difference has persisted

except for the oldest old where some studies have shown

that black mortality was lower than that of the white

population (13–15). Other researchers also have shown that

the black population has higher levels of ill health than the

white population. This difference persists even after

controlling for income and education (16). In this section,

racial group disparities in health outcomes will be analyzed

using different aspects of HLE, including years of life in

good or better health; expected years without limitation in

major activity; expected years without activities of daily

living; and expected years with a BMI less than 30.

3.3.1 Expected years in good or better health for

the white and black populations

To assess the disparities in self-rated health between the

black and white populations of the United States in 1995,

the percent in good or better health by 5-year age groups

and race were calculated using the 1995 NHIS data. The

results are presented in figure 3.11. Life tables were

constructed for the two groups separately by sex and

expected years in good or better health were computed. The

expected years in good or better health at selected ages are

presented in table 3.8. In 1995, a newly born white baby

could expect to live 76.6 years (73.7 years for a white male

baby and 79.5 years for a white female baby). In contrast, a

newly born black baby could expect to live 69.7 years (65.4

for a black male baby and 73.9 years for a black female

baby). This implies a difference of nearly 7 years (8 years

for males and about 5.5 years for females) between the life

expectancies of babies of the two races. Though the

difference between the races tends to decline with age, it

persists into old age. At age 65, for example, on average, the

white population could expect to live 17.6 years (16 years

for white males and 18.9 years for females), while the black

population could expect to live only 9 years (8.4 years for

black males and 9.6 years for black females).

A white baby born in 1995 could expect to spend 67.8

years (88.5 percent of life expectancy) in good or better

health versus only 56.9 years (81.6 percent of life

expectancy) for a black baby born the same year. The

difference in life with good or better health between the two

babies was nearly 11 years. The racial disparities in life with

good or better health declined with age, as did the difference

in life expectancies. At age 65, for example, the racial

disparity in life in good or better health was only 3.6 years.

Racial disparities in life with good or better health were

slightly larger between females than between males of the

two races. A white baby girl born in 1995 could expect to

spend 11.4 more years in good or better health than a black

baby girl born the same year. At age 65, a white female

could expect to spend 13.8 years (72.9 percent of her life

expectancy) in good or better health compared to a

65-year-old black female who could expect 9.6 years

(55.9 percent of her life expectancy) in good or better health.

A white male baby born in 1995 could expect to live 65.7

years (89.2 percent of his life) in good or better health. A

black male baby, on the other hand, could expect to spend

55.3 years (84.5 percent of his life expectancy) in good or

better health. At age 65, a white male expected to spend

11.4 more years of his life in good or better health, while a

black male of the same age expected to spend 8.4 years of

his remaining life in good or better health. Expected life in

good or better health at age 65 was 71.3 percent of life

20 Expected Years of Healthy Life Under Various Definitions of Health
Figure 3.11. Percentage in good or better health, by age and race: United States, 1995

expectancy for a white male; yet, it was only 60.1 percent

for a 65-year-old black male.

The last two columns of the table show the racial

differences both in life expectancy and expected years in

good or better health. For males as well as females, the

difference in years in good or better health is larger than the

difference in life expectancy. At any given age, the

difference in life expectancy is larger between males than

between females of the two races. On the other hand, the

difference in years in good or better health is larger between

females than between males of the two races. The difference

between the white and black population in expected years

with good or better health is statistically significant (p<0.05)

at all ages, except between white and black females at

age 80.

3.3.2 Expected years without any activity limitation

for the white and black populations

Figure 3.12 presents the percent of those who were free

of any type of activity limitation by age and race. The

percent of the population free of any activity limitation falls

with age for both racial groups. Age-specific prevalence

rates were combined with life table person-years lived to

estimate expected years free of activity limitation. The

expected years without limitation in any activity are

presented in table 3.9. In 1995, the white and black

populations could expect to spend a larger share of their

remaining lives free of any activity limitation. As expected,

life free of activity limitation as a percent of life expectancy

declined with age for males as well as females of both races.

In 1995, a 20-year-old white male could expect to spend

43.7 years (nearly 80 percent of his remaining life) without

any activity limitation. A 20-year-old black male, in contrast,

could expect to spend 36.2 years (about 76 percent of his

remaining life) free of any activity limitation. At age 65, the

expected years free of any activity limitation declined to

62.6 percent of life expectancy for white males and

58.1 percent of life expectancy for black males.

On average, a 20-year-old white female could expect to

live 47 more years (nearly 78 percent of her life expectancy)

free of any activity limitation. A white female of age 65

could expect to live 11.6 more years (61.4 percent of her life

expectancy) without any activity limitation. A 20-year-old

black female could expect to live about 40 more years

(72.5 percent of life expectancy) free of activity limitation,

whereas a 65-year-old black female could expect to live 8.6

more years (about half of her life expectancy) free of any

activity limitation. The difference between the white and

black populations in expected years without any activity

limitation is statistically significant (p<0.05) at all ages,

except at 75 years of age and over for males and at 80 years

of age and over for females.

As indicated in the last two columns of table 3.9, at any

given age, the difference in life expectancy between white

and black males is almost the same as the difference in

expected life free of any activity limitation. At older ages

Expected Years of Healthy Life Under Various Definitions of Health 21
Figure 3.12. Percentage free of any type of activity limitation, by age and race: United States, 1995

(70 years and older), the difference in life expectancy

without activity limitation is actually less than the difference

in overall life expectancy; this indicates that black men have

a greater proportion of life in a healthy state than white men.

For females, at any given age, the difference in life

expectancy between the races is smaller than the difference

in life without activity limitation. Though females could

expect to live more years (except after age 75 for the white

population and after age 70 for the black population) free of

activity limitation compared to males of the same age and

race, males could expect to spend a greater share of their life

expectancies free of any activity limitation.

3.3.3 Expected years without ADL or IADL limitation

for the white and black populations

The 1995 NHIS data were used to calculate percent of

the population able to perform personal care needs or not

limited in other routine needs of daily living by 5-year age

groups and race (figure 3.13). These results were used in

combination with life table estimates of person-years lived to

calculate expected years without ADL or IADL limitation.

Table 3.10 presents expected years without limitation in ADL

or other routine needs for the 1995 white and black

population by sex. The table indicates that ADL or IADL

limitation was strongly associated with old age. At the

younger ages, males and females of both races would expect

to live more than nine tenths of their lives free of ADL or

IADL limitation.

At age 65, however, the share of life expected to be free

of ADL or IADL limitation was about 87 percent for white

males, 83 percent for black males, about 80 percent for white

females, and slightly more than 72 percent for black females.

At age 80, the corresponding percentages were about 75 for

white males, 69 for black males, 63.5 for white females, and

53.5 for black females. At any given age, the racial

difference in life expectancy for males is almost the same as

the difference in life free of ADL or IADL limitation. For

females, on the other hand, the racial difference in life free

of ADL or IADL limitation was greater than the difference

in life expectancy. The difference between white and black

expected years without ADL or IADL limitation is

significant (p<0.05) at all ages, except at 80 years of age

and over for males and at 85 years of age and over for

females. Also, at each age and within each race, males could

expect to live a larger share of their lives free of any

limitation than females.

3.3.4 Expected years with BMI less than 30 for the

white and black populations

The percentage of the population aged 20 years and over

that is not obese (BMI less than 30) by 5-year age groups

and race was estimated using the 1994, 1995, and 1996

NHIS data, and the results are presented graphically in

figure 3.14. Expected years with BMI less than 30 were also

estimated using these distributions and estimates of

person-years lived from a 1995 abridged life table. The

22 Expected Years of Healthy Life Under Various Definitions of Health
Figure 3.13. Percentage able to perform personal care needs or not limited in other routine needs, by age and race: United States, 1995

Figure 3.14. Percentage not obese, by age and race: United States, 1994–96

Expected Years of Healthy Life Under Various Definitions of Health 23
average number of expected years with BMI less than 30 at

selected ages for the white and black populations are

presented in table 3.11. At any age, on average, the white

population could expect to spend a greater percentage of

their lives with BMI less than 30 than the black population.

At age 20, for example, the percentage of life expectancy

that was expected to be with BMI less than 30 was 83.9 for

the white population of both sexes and 73.8 for the black

population. At age 65, the percentages rose slightly to 86.2

for the white population and to 74.8 percent for the black

population.

On average, the percentage of remaining life that was

expected to be with BMI less than 30 for white males was

83.6 at age 20, 87.8 at age 65, and 94 at age 80. For black

males, it was 79.5 at age 20, 84.1 at age 65, and 94.3 at age

80. For white females, on average, the percentage of

remaining life that was expected to be with BMI less than

30 was 84.3 at age 20, about 85 at age 65, and 90.5 at age

80. For black females, the corresponding percentages were

69.3 at age 20, 69 percent at age 65, and about 80 percent at

age 80.

At any age, the difference between white and black

males in expected years with BMI less than 30 was about

the same as the difference in life expectancy. On the other

hand, the difference between white and black females in

average expected years with BMI less than 30 was almost

three times larger than the difference in their expectation of

life. The difference between the white and black populations

in expected years with BMI less than 30 is statistically

significant (p<0.05) at all ages, except at 85 years of age

and over for males.

3.4 Comparison of Results from the Various

Measures of Health

Estimates of healthy life expectancy under various

definitions of health were provided in sections 3.2 and 3.3.

The main purpose of providing these results was to illustrate

the application of the method and interpretation of the

results. A second, even more important purpose of estimating

healthy life expectancies under the various definitions of

health was to analyze the variation of the results across the

measures. Analyzing the results across the measures is

important because the magnitude and pattern of the variation

across measures provide answers to health-related questions

with important policy implications.

This section presents a comparison of the results across

measures. Results across measures will be compared first for

the adult population at 30 and 65 years of age. This will be

followed by a comparison of the results at age 65 for males

and females separately. Results will also be compared across

measures by sex and age, followed by race and age.

Measures used for the comparison include expected life

Figure 3.15. Life expectancy and expected years of healthy life under different definitions of health at 30 years of age, both sexes:

United States, 1995

NOTE: ADL refers to activities of daily living; IADL refers to instrumental activities of daily living.

24 Expected Years of Healthy Life Under Various Definitions of Health
without the need for help in ADL (also ADL or IADL);

years able to perform major activities; years without any

activity limitation; years in good or better health; and years

in excellent health. Also included are expected years without

chronic diabetes, heart disease, hypertension, and arthritis.

3.4.1 Comparison across measures at 30 and 65

years of age

Life expectancies and expected years of healthy life for

the total population at 30 and 65 years of age are presented

in table 3.12 and figures 3.15 and 3.16. In 1995, on average,

a 35-year-old would expect to live 47.5 more years.

Regardless of the health measure used, most of the

remaining years of life were expected to be healthy. On the

other hand, the number of years of healthy life varied by

type of measure used. The expected number of years of

healthy life was 44.5 years (nearly 94 percent of life

expectancy at age 30) when measured in terms of expected

years without the need for help in ADL, while it was 34.7

years (73.1 percent of life expectancy) when measured in

terms of years free of chronic arthritis. Expected years of

healthy life at age 30 based on self-assessed health (good or

better) was 39 years (82.1 percent of life expectancy).

3.4.2 Comparison across measures for males and

females at 65 years of age

In 1995, 65-year-old males could expect to live an

additional 15.9 years, and females could expect to live 18.8

years (table 3.13 and figures 3.17 and 3.18). At 65, males

could also expect to perform their major activities for nearly

89 percent of their remaining years. They could expect to

spend more than 70 percent of their life expectancy in good

or better health and only spend 5.7 years of their life

expectancy with heart disease. They would not expect to

need the help of another person in carrying out their ADL or

IADL.

At age 65, females could expect to live 18.8 more years.

According to almost all the health measures used (with the

exception of expected years with chronic arthritis), more

than half of their life expectancy would be spent in healthy

life. On average, they could expect to spend 13.4 years

(71.3 percent of life expectancy) in good or better health and

could expect to be able to perform their major activities for

16.8 years. They would not expect to need the help of

another person in the course of their ADL for 92 percent of

their remaining years. On the other hand, they could expect

to spend 10.4 (55.3 percent) years of their life expectancy

with chronic arthritis.

Figure 3.16. Life expectancy and expected years of healthy life under different definitions of health at 65 years of age, both sexes:

United States, 1995

NOTE: ADL refers to activities of daily living; IADL refers to instrumental activities of daily living.

Expected Years of Healthy Life Under Various Definitions of Health 25
Figure 3.17. Life expectancy and expected years of healthy life for males under different definitions of health at 65 years of age:

United States, 1995

NOTE: ADL refers to activities of daily living; IADL refers to instrumental activities of daily living.

Figure 3.18. Life expectancy and expected years of healthy life for females under different definitions of health at 65 years of age: United

States, 1995

NOTE: ADL refers to activities of daily living; IADL refers to instrumental activities of daily living.

26 Expected Years of Healthy Life Under Various Definitions of Health
Figure 3.19. Life expectancy and expected years of healthy life

for the white population under different definitions of health at

65 years of age: United States, 1995

NOTE: ADL refers to activities of daily living; IADL refers to instrumental

activities of daily living.

3.4.3 Comparison across measures for the white

and black populations at 65 years of age

In 1995, life expectancy at age 65 was 17.6 years for the 

white population and 15.8 years for the black population. 

Table 3.14 and figures 3.19 and 3.20 present HLE at age 65 

for each race using six different definitions of health. For 

each race the expected years of healthy life at age 65 varied 

by health measure. The white population could expect to live 

12.7 years (72.2 percent of life expectancy at age 65) in 

good or better health and 10.9 years (almost 62 percent of 

average life expectancy at age 65) without any activity 

limitation. The black population could expect to spend 9.1 

years of the total life expectancy of 15.5 years in good or 

better health. 

3.4.4 Comparison across measures by age, sex,

and race

Expected years of healthy life varied by measure even 

when controlling for age, sex, and race. This is expected 

because the health state definition used in each measure was 

based on different dimensions of health. The observed 

variations in the results are important because, in addition to 

shedding some light on the within- and across-group 

variations in health, these variations are also indicative of 

the absolute necessity to use multiple measures to assess the 

various dimensions of population health. 

Age-specific health disparities between males and 

females estimated using six measures including life 

expectancy are presented in figure 3.21, and age-specific 

health disparities between the white and the black population 

estimated using the same six measures are presented in 

figure 3.22. Figure 3.21 shows the age-specific ratios of 

female and male HLEs. At a given age, a ratio in excess of 

Figure 3.20. Life expectancy and expected years of healthy life

for the black population under different definitions of health at

65 years of age: United States, 1995

NOTE: ADL refers to activities of daily living; IADL refers to instrumental

activities of daily living.

1 implies a higher female life expectancy compared to that 

of males; a ratio less than 1 indicates a higher life 

expectancy for males compared to that of females of the 

same age. Figure 3.22 depicts the ratio of health expectancy 

for the white population (and life expectancy) compared to 

that for the black population. Holding age constant, a ratio 

in excess of 1 implies a higher health expectancy for the 

white population compared to that of the black population. 

Figure 3.21 shows that health disparities between males 

and females varied by measure. The implied variations are 

smaller at the younger ages and much larger at the older 

ages. The smallest health disparities between males and 

females are observed when the health measure used is 

‘‘expected years without needing help in ADL or IADL.’’ 

The largest disparities were observed when health is 

measured using ability to perform major activity at younger 

and middle ages; at the older ages, the largest disparities 

were observed when health is measured using expected years 

in good or better health. All measures implied higher female 

healthy life expectancy (and life expectancy) at all ages 

except expected years without needing help in ADL or IADL 

and expected years without any limitation, both at age 80. 

The differences in expectation of life and HLE between 

the white and black population by type of measure are 

presented in figure 3.22. The health disparity pattern between 

the two races is different from the health disparity pattern 

between males and females (figure 3.21). Health disparities 

by measure varied more between races than between sexes. 

The disparity between the white and the black population is 

lowest when measured by life expectancy. Conversely, life 

expectancy was one of the two measures that implied the 

largest health disparities between males and females at 

almost every age. 

The six measures have clearly shown that using different 

health measures result in different patterns and magnitudes 

Expected Years of Healthy Life Under Various Definitions of Health 27
Figure 3.21. Sex disparities in health under various definitions of health status, by age: United States, 1995

of health disparities between population groups. While part 

of the variations in health disparities result from the 

difference in the measure used, part of the observed 

variation might have resulted from other factors exogenous 

to the health measure used. In addition to the different 

methods used, HLE estimates are affected by the health data 

used in their estimation. Healthy life expectancy for all 

measures was estimated using data from NHIS, a survey 

which does not include data on the institutionalized 

population. To the extent that the age, sex, racial 

composition, and health status of the institutional population 

is different from that of the noninstitutionalized civilian 

population (which NHIS covers), estimated HLEs would be 

expected to be biased differently by age, sex, and race. Male 

and female expected years without any activity limitation 

will be used to illustrate the pattern and magnitude of bias 

that could be introduced by not including the nursing home 

population in the estimation of the prevalence of activity 

limitation. 

References

1.

Verbrugge LM, Lepkowski JM, Imanaka Y. Comorbidity and 

its impact on disability. Milbank Q 67(3–4):450–84. 1989. 

2.

House JS, et al. Age, socioeconomic status and health. 

Milbank Q 68(3):383–411. 1990. 

3.

Crimmins EM. Mixed trends in population health among older 

adults. J Gerontol B Psychol Sci Soc Sci 51B:S223–5. 1996. 

4.

Nusselder W. A multistate life-table analysis of health 

expectancy for the Netherlands. In Compression or expansion 

of morbidity? A life-table approach. Thesis Publishers, pp. 

85–128. Amsterdam. 1988. 

5.

Benson V, Marano MA. Current estimates from the National 

Health Interview Survey, 1995. National Center for Health 

Statistics. Vital Health Stat 10(199). 1998. 

6.

Wagener DK, Molla MT, Crimmins EM, Pamuk E, Madans 

JH. Summary measures of population health: Addressing the 

first goal of Healthy People 2010, improving health 

expectancy. Statistical Notes, no 22. Hyattsville, Maryland: 

National Center for Health Statistics. September 2001. 

7.

National Institutes of Health. Clinical guidelines on the 

identification, evaluation, and treatment of overweight and 

obesity in adults. The Evidence Report. NIH Publication 

98(4083). September 1998. 

28 Expected Years of Healthy Life Under Various Definitions of Health
Figure 3.22. Racial disparities in health between white and black populations under various definitions of health status, by age:

United States, 1995

8.World Health Organization. Obesity: Preventing and managing 

the global epidemic. WHO Technical Report Series 894. 

Geneva, Switzerland: World Health Organization. 2000. 

9.National Center for Health Statistics. Health, United States, 

2002 with chartbook on trends in health of Americans. pp. 

213–14. Hyattsville, Maryland. 2002. 

10.Rogers RG. Living and dying in the U.S.A.: Socioeconomic 

determinants of death among blacks and whites. Demography 

29(2):287–303. 1992. 

11. Hayward MD, Heron M. Racial inequality in active life 

among adult Americans. Demography 36(1):77–91. 1999. 

12.Hoyert DL, Arias E, Smith BL, Murphy SL, Kochanek KD. 

Deaths: Final Data for 1999. National vital statistics reports; 

vol 49 no 8. Hyattsville, Maryland: National Center for Health 

Statistics. 2001. 

13.Manton KG, et al. The black/white crossover: Investigation 

from the perspectives of the components of aging. 

Gerontologist 19:291–99. 1979. 

14.Kestenbaum B. A description of the extreme aged population 

based on improved medicare enrollment data. Demography 

29(4):565–80. 1992. 

15.Elo IT, Preston SH. Estimating African-American mortality 

from inaccurate data. Demography 31:427–58. 1994. 

16.Williams, D. R. Race/ethnicity and socioeconomic status: 

Measurement and methodological issues. Int J Health Serv 

26(3):483–505. 1996. 

Expected Years of Healthy Life Under Various Definitions of Health 29
Table 3.1. Life expectancies and expected years in good or better health and excellent health for selected ages, by sex:

United States, 1995

Expected Years in good Expected Years in

Expected years in or better health years in excellent health

years of good or asa%of life excellent asa%of life

Sex and age life better health expectancy health expectancy

Both sexes

Birth ................................ 75.8 66.5 87.7 26.4 34.8

20 years .............................. 56.9 48.0 84.3 16.5 29.0

30 years .............................. 47.5 39.0 82.1 12.7 26.6

45 years .............................. 33.8 26.2 77.5 7.3 21.7

65 years .............................. 17.5 12.4 71.0 2.6 14.9

70 years .............................. 14.1 9.8 69.7 2.0 13.9

75 years .............................. 11.1 7.4 67.4 1.4 13.1

80 years .............................. 8.3 5.4 65.3 1.1 13.0

Male

Birth ................................ 72.8 64.6 88.7 27.1 37.3

20 years .............................. 54.0 46.2 85.5 17.2 31.9

30 years .............................. 44.9 37.3 83.1 13.0 29.0

45 years .............................. 31.5 24.6 78.1 7.4 23.3

65 years .............................. 15.9 11.2 70.4 2.4 14.9

70 years .............................. 12.8 8.8 68.9 1.7 13.6

75 years .............................. 10.1 6.7 66.5 1.2 11.8

80 years .............................. 7.7 4.9 64.2 0.8 10.8

Female

Birth ................................ 78.8 68.4 86.8 25.7 32.6

20 years .............................. 59.8 49.8 83.3 15.8 26.4

30 years .............................. 50.1 40.6 81.2 12.3 24.6

45 years .............................. 35.9 27.6 76.9 7.3 20.2

65 years .............................. 18.8 13.4 71.3 2.8 14.8

70 years .............................. 15.1 10.6 70.1 2.1 14.0

75 years .............................. 11.7 8.0 67.9 1.6 13.7

80 years .............................. 8.7 5.7 65.9 1.2 14.2

Gender difference1

Birth ................................ †6.1 †3.9 ... –1.4 ...

20 years .............................. †

5.7 †3.6 ... –1.4 ...

30 years .............................. †

5.2 †3.4 ... –0.7 ...

45 years .............................. †

4.3 †3.0 ... –0.1 ...

65 years .............................. †

2.9 †2.2 ... 0.4 ...

70 years .............................. †

2.3 †1.8 ... 0.4 ...

75 years .............................. †

1.7 †1.3 ... 0.4 ...

80 years .............................. †

1.0 †0.8 ... 0.4 ...

†Statistically significant (p <0.05).

. . . Category not applicable.

1Calculated by subtracting expected years for males from expected years for females.

SOURCES: Estimated based on data from the Division of Vital Statistics, National Health Interview Surveys, National Center for Health Statistics; and the U.S. Census Bureau.

30 Expected Years of Healthy Life Under Various Definitions of Health
Table 3.2. Life expectancies and expected years without limitation in activity for selected ages, by sex and type of

activity: United States, 1995

Years without Years without

Expected major activity Expected any activity

Expected years without limitation as years without limitation as

years of major activity a % of life any activity a % of life

Sex and age life limitation expectancy limitation expectancy

Both sexes

Birth ................................ 75.8 71.6 94.4 62.5 82.5

20 years .............................. 56.9 52.8 92.7 44.7 78.5

30 years .............................. 47.5 43.5 91.6 35.9 75.5

45 years .............................. 33.8 30.3 89.5 23.6 69.8

65 years .............................. 17.5 15.6 89.1 10.7 61.3

70 years .............................. 14.1 12.9 91.3 8.5 60.4

75 years .............................. 11.1 9.8 88.7 6.1 55.5

80 years .............................. 8.3 7.1 85.1 4.1 49.7

Male

Birth ................................ 72.8 68.5 94.1 60.5 83.2

20 years .............................. 54.0 49.8 92.2 43.0 79.6

30 years .............................. 44.9 40.8 90.9 34.4 76.8

45 years .............................. 31.5 27.9 88.6 22.5 71.2

65 years .............................. 15.9 14.1 88.6 9.9 62.4

70 years .............................. 12.8 11.8 92.6 8.0 62.4

75 years .............................. 10.1 9.1 90.2 5.9 58.9

80 years .............................. 7.7 6.8 88.1 4.3 55.4

Female

Birth ................................ 78.8 74.7 94.7 64.6 81.9

20 years .............................. 59.8 55.7 93.1 46.3 77.5

30 years .............................. 50.1 46.1 92.2 37.3 74.4

45 years .............................. 35.9 32.4 90.3 24.6 68.6

65 years .............................. 18.8 16.8 89.5 11.4 60.6

70 years .............................. 15.1 13.7 90.5 8.9 59.2

75 years .............................. 11.7 10.3 87.8 6.3 53.6

80 years .............................. 8.7 7.2 83.4 4.0 46.6

Gender difference1

Birth ................................ †6.1 †6.2 ... †4.0 ...

20 years .............................. †

5.7 †5.9 ... †3.3 ...

30 years .............................. †

5.2 †5.4 ... †2.8 ...

45 years .............................. †

4.3 †4.5 ... †2.2 ...

65 years .............................. †

2.9 †2.8 ... †1.5 ...

70 years .............................. †

2.3 †1.8 ... †1.0 ...

75 years .............................. †

1.7 †1.2 ... †0.4 ...

80 years .............................. †

1.0 †0.4 ... –0.2 ...

†Statistically significant (p <0.05).

. . . Category not applicable.

1Calculated by subtracting expected years for males from expected years for females.

SOURCES: Estimated based on data from the Division of Vital Statistics, National Health Interview Surveys, National Center for Health Statistics; and the U.S. Census Bureau.

Expected Years of Healthy Life Under Various Definitions of Health 31
Table 3.3. Life expectancies and expected years without work limitation for selected ages, by sex: United States, 1995

Years able Expected Years without

Expected Expected to work years without work limitation

years of years able asa%of life work asa%of life

Sex and age life to work expectancy limitation expectancy

Both sexes

20 years .............................. 56.9 53.1 93.4 50.7 89.1

30 years .............................. 47.5 43.9 92.4 41.8 87.9

45 years .............................. 33.8 30.8 91.0 29.2 86.3

65 years .............................. 17.5 16.5 94.6 16.1 92.3

20 to 69 years .......................... 42.8 39.0 91.2 36.6 85.5

Male

20 years .............................. 54.0 50.3 93.1 47.9 88.7

30 years .............................. 44.9 41.3 92.1 39.2 87.3

45 years .............................. 31.5 28.5 90.4 26.9 85.5

65 years .............................. 15.9 14.9 93.6 14.4 90.7

20 to 69 years .......................... 41.2 37.5 91.0 35.1 85.2

Female

20 years .............................. 59.8 55.9 93.6 53.5 89.5

30 years .............................. 50.1 46.4 92.8 44.3 88.4

45 years .............................. 35.9 32.8 91.5 31.2 87.0

65 years .............................. 18.8 17.9 95.3 17.6 93.4

20 to 69 years .......................... 44.6 40.8 91.4 38.3 85.9

Gender difference1

20 years .............................. †5.7 †5.6 ... †5.5 ...

30 years .............................. †

5.2 †5.2 ... †5.1 ...

45 years .............................. †

4.3 †4.3 ... †4.3 ...

65 years .............................. †

3.0 †3.0 ... †3.2 ...

†Statistically significant (p <0.05).

. . . Category not applicable.

1Calculated by subtracting expected years for males from expected years for females.

SOURCES: Estimated based on data from the Division of Vital Statistics, National Health Interview Surveys, National Center for Health Statistics; and the U.S. Census Bureau.

32 Expected Years of Healthy Life Under Various Definitions of Health
Table 3.4. Life expectancies and expected years without functional dependency for selected ages, by sex: United States,

1995

Expected Years without Expected Years without

Expected years without ADL help years without ADL or IADL

years of needing help asa%of life needing help help asa%of

Sex and age life in ADL1 expectancy1 in ADL or IADL1–2 life expectancy1–2

Both sexes

5 years .............................. 71.5 70.1 98.0 67.8 94.7

20 years .............................. 56.9 55.5 97.5 53.2 93.4

30 years .............................. 47.5 46.1 97.1 43.8 92.3

45 years .............................. 33.8 32.4 96.0 30.3 89.7

65 years .............................. 17.5 16.2 92.8 14.5 82.7

70 years .............................. 14.1 12.9 91.3 11.2 79.3

75 years .............................. 11.1 9.8 88.7 8.2 73.9

80 years .............................. 8.3 7.1 85.1 5.5 66.8

Male

5 years .............................. 68.5 67.3 98.2 65.8 96.0

20 years .............................. 54.0 52.9 97.9 51.3 95.1

30 years .............................. 44.9 43.7 97.5 42.2 94.1

45 years .............................. 31.5 30.4 96.5 29.0 92.1

65 years .............................. 15.9 14.9 93.8 13.8 86.5

70 years .............................. 12.8 11.8 92.6 10.7 83.9

75 years .............................. 10.1 9.1 90.2 8.0 79.6

80 years .............................. 7.7 6.8 88.1 5.7 74.4

Female

5 years .............................. 74.5 72.8 97.7 69.7 93.6

20 years .............................. 59.8 58.1 97.2 55.0 92.1

30 years .............................. 50.1 48.4 96.7 45.4 90.7

45 years .............................. 35.9 34.3 95.6 31.5 87.8

65 years .............................. 18.8 17.3 92.2 15.1 80.1

70 years .............................. 15.1 13.7 90.5 11.5 76.3

75 years .............................. 11.7 10.3 87.8 8.3 70.6

80 years .............................. 8.7 7.2 83.4 5.4 62.8

Gender difference3

Birth ................................ †6.1 †5.5 ... †3.9 ...

20 years .............................. †

5.7 †5.2 ... †3.7 ...

30 years .............................. †

5.2 †4.7 ... †3.2 ...

45 years .............................. †

4.3 †3.9 ... †2.5 ...

65 years .............................. †

2.9 †2.4 ... †1.3 ...

70 years .............................. †

2.3 †1.8 ... †0.8 ...

75 years .............................. †

1.7 †1.2 ... †0.3 ...

80 years .............................. †

1.0 †0.4 ... –0.3 ...

†Statistically significant (p <0.05).

. . . Category not applicable.

1ADL refers to activities of daily living.

2IADL refers to instrumental activities of daily living.

3Calculated by subtracting expected years for males from expected years for females.

SOURCES: Estimated based on data from the Division of Vital Statistics, National Health Interview Surveys, National Center for Health Statistics; and the U.S. Census Bureau.

Expected Years of Healthy Life Under Various Definitions of Health 33
Table 3.5. Life expectancies and expected years without chronic arthritis and chronic heart diseases for selected ages, by

sex: United States, 1994–96

Years without

Expected Years without Expected chronic heart

Expected years without chronic arthritis years without diseases

years of chronic asa%of life chronic heart asa%of life

Sex and age life arthritis expectancy diseases expectancy

Both sexes

30 years .............................. 47.5 34.7 73.0 40.0 84.1

45 years .............................. 33.8 21.6 63.9 26.7 79.0

65 years .............................. 17.5 8.8 50.2 12.1 69.1

70 years .............................. 14.1 6.8 48.2 9.4 66.5

75 years .............................. 11.1 5.1 46.1 7.1 64.2

80 years .............................. 8.3 3.8 45.9 5.3 64.1

Male

30 years .............................. 44.9 35.4 78.8 37.1 82.8

45 years .............................. 31.5 22.5 71.3 24.0 76.1

65 years .............................. 15.9 9.2 58.1 10.2 64.5

70 years .............................. 12.8 7.1 55.6 7.7 60.6

75 years .............................. 10.1 5.7 56.2 5.8 57.6

80 years .............................. 7.7 4.2 54.0 4.5 58.8

Female

30 years .............................. 50.1 34.0 68.0 42.7 85.3

45 years .............................. 35.9 20.8 57.9 29.2 81.3

65 years .............................. 18.8 8.4 44.8 13.6 72.3

70 years .............................. 15.1 6.6 43.6 10.6 70.4

75 years .............................. 11.7 4.7 40.1 8.0 68.1

80 years .............................. 8.7 3.6 41.6 5.8 67.0

Gender difference1

30 years .............................. †5.2 †–1.3 . . . †5.6 ...

45 years .............................. †

4.3 †–1.7 . . . †5.2 ...

65 years .............................. †

2.9 †–0.8 . . . †3.3 ...

70 years .............................. †

2.3 †–0.5 . . . †2.9 ...

75 years .............................. †

1.7 †–0.9 . . . †2.2 ...

80 years .............................. †

1.0 †–0.6 . . . †1.3 ...

†Statistically significant (p <0.05).

. . . Category not applicable.

1Calculated by subtracting expected years for males from expected years for females.

SOURCES: Estimated based on data from the Division of Vital Statistics, National Health Interview Surveys, National Center for Health Statistics; and the U.S. Census Bureau.

34 Expected Years of Healthy Life Under Various Definitions of Health
Table 3.6. Life expectancies and expected years without chronic hypertension and chronic diabetes for selected ages, by

sex: United States, 1994–96

Years without

Expected chronic Expected Years without

Expected years without hypertension years without chronic diabetes

years of chronic asa%of life chronic asa%of life

Sex and age life hypertension expectancy diabetes expectancy

Both sexes

30 years .............................. 47.5 36.8 77.4 44.5 93.7

45 years .............................. 33.8 23.8 70.3 30.9 91.6

65 years .............................. 17.5 10.9 62.1 15.6 89.3

70 years .............................. 14.1 8.5 60.4 12.6 89.1

75 years .............................. 11.1 6.7 60.6 9.9 89.6

80 years .............................. 8.3 5.3 63.5 7.6 91.7

Male

30 years .............................. 44.9 35.7 79.5 42.0 93.7

45 years .............................. 31.5 23.0 73.1 28.8 91.3

65 years .............................. 15.9 10.8 68.0 14.0 88.3

70 years .............................. 12.8 8.6 67.6 11.2 88.0

75 years .............................. 10.1 6.9 68.7 8.9 88.2

80 years .............................. 7.7 5.6 72.3 6.9 89.3

Female

30 years .............................. 50.1 37.9 75.7 46.9 93.6

45 years .............................. 35.9 24.5 68.2 32.9 91.8

65 years .............................. 18.8 10.9 58.1 16.9 89.9

70 years .............................. 15.1 8.5 55.9 13.6 89.8

75 years .............................. 11.7 6.6 55.9 10.6 90.5

80 years .............................. 8.7 5.1 58.9 8.1 93.0

Gender difference1

30 years .............................. †5.2 †2.2 ... †4.9 ...

45 years .............................. †

4.3 †1.4 ... †4.1 ...

65 years .............................. †

2.9 0.1 ... †2.9 ...

70 years .............................. †

2.3 –0.2 . . . †2.3 ...

75 years .............................. †

1.7 †–0.3 . . . †1.7 ...

80 years .............................. †

1.0 †–0.5 . . . †1.2 ...

†Statistically significant (p < 0.05).

. . . Category not applicable.

1Calculated by subtracting expected years for males from expected years for females.

SOURCES: Estimated based on data from the Division of Vital Statistics, National Health Interview Surveys, National Center for Health Statistics; and the U.S. Census Bureau.

Expected Years of Healthy Life Under Various Definitions of Health 35
Table 3.7. Life expectancies and expected years with body mass index less than 25 and years with body mass index less

than 30 for selected ages, by sex: United States, 1994–96

Years with Years with

Expected BMI1 Expected BMI1

Expected years with less than 25 years with less than 30

years of BMI1 asa%of life BMI1 asa%of life

Sex and age life less than 25 expectancy less than 30 expectancy

Both sexes

20 years .............................. 56.9 27.9 49.0 47.6 83.7

30 years .............................. 47.5 22.0 46.4 39.3 82.7

45 years .............................. 33.8 15.2 44.9 27.8 82.4

65 years .............................. 17.5 8.8 50.4 15.0 85.8

70 years .............................. 14.1 7.5 53.5 12.3 87.5

75 years .............................. 11.1 6.4 57.9 9.9 89.6

80 years .............................. 8.3 5.3 63.6 7.6 91.5

Male

20 years .............................. 54.0 21.6 40.0 45.4 84.0

30 years .............................. 44.9 16.7 37.1 37.3 83.1

45 years .............................. 31.5 11.6 36.8 26.2 83.1

65 years .............................. 15.9 7.1 44.9 14.0 88.0

70 years .............................. 12.8 6.2 48.8 11.5 90.0

75 years .............................. 10.1 5.5 54.2 9.3 92.2

80 years .............................. 7.7 4.6 60.3 7.3 94.2

Female

20 years .............................. 59.8 34.2 57.2 49.8 83.4

30 years .............................. 50.1 27.4 54.6 41.2 82.4

45 years .............................. 35.9 18.6 51.8 29.3 81.8

65 years .............................. 18.8 10.2 54.3 15.8 84.2

70 years .............................. 15.1 8.6 56.6 13.0 85.9

75 years .............................. 11.7 7.1 60.2 10.3 88.0

80 years .............................. 8.7 5.7 65.3 7.8 90.1

Gender difference2

20 years .............................. †5.7 †12.6 . . . †4.5 ...

30 years .............................. †

5.2 †10.7 . . . †4.0 ...

45 years .............................. †

4.3 †7.0 ... †3.1 ...

65 years .............................. †

2.9 †3.1 ... †1.9 ...

70 years .............................. †

2.3 †2.3 ... †1.5 ...

75 years .............................. †

1.7 †1.6 ... †1.1 ...

80 years .............................. †

1.0 †1.0 ... †0.5 ...

†Statistically significant (p <0.05).

. . . Category not applicable.

1BMI refers to body mass index.

2Calculated by subtracting expected years for males from expected years for females.

SOURCES: Estimated based on data from the Division of Vital Statistics, National Health Interview Surveys, National Center for Health Statistics; and the U.S. Census Bureau.

36 Expected Years of Healthy Life Under Various Definitions of Health
Table 3.8. Life expectancies and expected years in good or better health for selected ages of the white and black

population, by sex: United States, 1995

White Black Difference in years

Expected Years in good Expected Years in good Expected

Expected years in or better health Expected years in or better health Expected years in

years of good or asa%of life years of good or asa%of life years of good or

Sex and age life better health expectancy life better health expectancy life better health

Both sexes

Birth ............... 76.6 67.8 88.5 69.7 56.9 81.6 †

6.8 †10.9

20 years ............. 57.5 49.1 85.4 51.5 39.1 75.9 †

6.0 †10.0

30 years ............. 48.0 40.0 83.3 42.5 30.8 72.4 †

5.5 †9.2

45 years ............. 34.2 26.9 78.8 29.9 19.6 65.4 †

4.2 †7.3

65 years ............. 17.6 12.7 72.2 15.8 9.1 57.6 †

1.8 †3.6

70 years ............. 14.2 10.0 70.7 12.8 7.4 58.0 †

1.4 †2.6

75 years ............. 11.1 7.6 68.4 10.4 5.7 55.3 †

0.7 †1.9

80 years ............. 8.3 5.5 66.5 8.0 4.2 52.5 †

0.4 †1.4

Male

Birth ............... 73.7 65.7 89.2 65.4 55.3 84.5 †

8.2 †10.5

20 years ............. 54.8 47.2 86.2 47.4 37.7 79.5 †

7.3 †9.5

30 years ............. 45.5 38.1 83.9 38.8 29.7 76.4 †

6.7 †8.5

45 years ............. 32.0 25.2 79.0 26.9 18.7 69.6 †

5.1 †6.5

65 years ............. 16.0 11.4 71.3 14.0 8.4 60.1 †

2.1 †3.0

70 years ............. 12.9 9.0 69.6 11.3 6.8 59.9 †

1.5 †2.2

75 years ............. 10.1 6.8 67.3 9.3 5.3 57.6 †

0.8 †1.4

80 years ............. 7.7 5.0 65.2 7.3 3.9 54.0 †

0.4 †1.1

Female

Birth ............... 79.5 69.8 87.9 73.9 58.4 79.1 †

5.6 †11.4

20 years ............. 60.2 51.0 84.7 55.4 40.5 73.1 †

4.8 †10.5

30 years ............. 50.5 41.8 82.7 46.0 31.8 69.2 †

4.5 10.0

45 years ............. 36.2 28.5 78.7 32.6 20.3 62.3 †

3.6 †8.1

65 years ............. 18.9 13.8 72.9 17.1 9.6 55.9 †

1.8 †4.2

70 years ............. 15.2 10.8 71.4 13.9 7.9 56.8 †

1.3 †3.0

75 years ............. 11.8 8.1 69.1 11.1 6.0 54.0 †

0.7 †2.2

80 years ............. 8.7 5.8 67.1 8.3 4.3 51.6 †

0.4 †1.5

†Statistically significant (p <0.05).

SOURCES: Estimated based on data from the Division of Vital Statistics, National Health Interview Surveys, National Center for Health Statistics; and the U.S. Census Bureau.

Expected Years of Healthy Life Under Various Definitions of Health 37
Table 3.9. Life expectancies and expected years without any type of activity limitation for selected ages of the white and

black population, by sex: United States, 1995

White Black Difference in years

Expected Years without Expected Years without Expected

years any activity years any activity years

Expected without limitation Expected without limitation Expected without

years any activity asa%of life years any activity asa%of life years any activity

Sex and age of life limitation expectancy of life limitation expectancy of life limitation

Both sexes

Birth ............... 76.6 63.4 82.7 69.7 55.4 79.4 †

6.8 †7.9

20 years ............. 57.5 45.4 78.8 51.5 38.3 74.3 †

6.0 †7.1

30 years ............. 48.0 36.5 76.0 42.5 29.9 70.3 †

5.5 †6.6

45 years ............. 34.2 24.0 70.4 29.9 18.7 62.6 †

4.2 †5.3

65 years ............. 17.6 10.9 61.8 15.8 8.4 53.5 †

1.8 †2.5

70 years ............. 14.2 8.6 60.6 12.8 7.2 56.3 †

1.4 †1.4

75 years ............. 11.1 6.2 55.8 10.4 5.2 50.2 †

0.7 †1.0

80 years ............. 8.3 4.1 49.6 8.0 3.7 46.9 †

0.4 0.4

Male

Birth ............... 73.7 61.4 83.3 65.4 52.9 80.8 †

8.2 †8.5

20 years ............. 54.8 43.7 79.9 47.4 36.2 76.3 †

7.3 †7.6

30 years ............. 45.5 35.1 77.1 38.8 28.2 72.7 †

6.7 †6.9

45 years ............. 32.0 22.9 71.5 26.9 17.9 66.5 †

5.1 †5.0

65 years ............. 16.0 10.0 62.6 14.0 8.1 58.1 †

2.1 †1.9

70 years ............. 12.9 8.0 62.3 11.3 7.0 61.7 †

1.5 †1.0

75 years ............. 10.1 5.9 58.8 9.3 5.6 60.0 †

0.8 0.4

80 years ............. 7.7 4.2 55.1 7.3 4.3 58.4 †

0.4 0.0

Female

Birth ............... 79.5 65.3 82.2 73.9 57.8 78.2 †

5.6 †7.5

20 years ............. 60.2 47.0 77.9 55.4 40.2 72.5 †

4.8 †6.8

30 years ............. 50.5 37.9 75.0 46.0 31.4 68.3 †

4.5 †6.5

45 years ............. 36.2 25.1 69.4 32.6 19.5 59.7 †

3.6 †5.7

65 years ............. 18.9 11.6 61.4 17.1 8.6 50.4 †

1.8 †3.0

70 years ............. 15.2 9.0 59.5 13.9 7.4 53.1 †

1.3 †1.7

75 years ............. 11.8 6.4 54.0 11.1 5.0 45.0 †

0.7 †1.4

80 years ............. 8.7 4.1 46.7 8.3 3.4 41.4 †

0.4 0.6

†Statistically significant (p < 0.05).

SOURCES: Estimated based on data from the Division of Vital Statistics, National Health Interview Surveys, National Center for Health Statistics; and the U.S. Census Bureau.

38 Expected Years of Healthy Life Under Various Definitions of Health
Table 3.10. Life expectancies and expected years without limitation in personal care or other routine needs for selected

ages of the white and black populations, by sex: United States, 1995

White Black Difference in years

Expected Years without Expected Years without Expected

Expected years without ADL or IADL1 Expected years without ADL or IADL1 Expected years without

years of needing help help asa%of years of needing help help asa%of years of needing help

Sex and age life in ADL or IADL1 life expectancy life in ADL or IADL1 life expectancy life in ADL or IADL1

Both sexes

5 years ............. 72.2 68.5 94.9 66.0 61.5 93.2 †

6.2 †7.0

20 years ............. 57.5 53.9 93.7 51.5 47.1 91.4 †

6.0 †6.8

30 years ............. 48.0 44.5 92.5 42.5 38.2 89.8 †

5.5 †6.3

45 years ............. 34.2 30.8 90.1 29.9 25.7 86.0 †

4.2 †5.0

65 years ............. 17.6 14.6 83.2 15.8 12.1 76.5 †

1.8 †2.6

70 years ............. 14.2 11.3 79.8 12.8 9.4 73.3 †

1.4 †1.9

75 years ............. 11.1 8.3 74.6 10.4 6.8 65.7 †

0.7 †1.5

80 years ............. 8.3 5.6 67.5 8.0 4.7 58.6 †

0.4 †0.9

Male

5 years ............. 69.3 66.6 96.1 61.7 58.6 95.0 †

7.6 †8.0

20 years ............. 54.8 52.1 95.2 47.4 44.4 93.7 †

7.3 †7.7

30 years ............. 45.5 42.9 94.3 38.8 35.9 92.5 †

6.7 †7.0

45 years ............. 32.0 29.5 92.3 26.9 24.2 90.0 †

5.1 †5.3

65 years ............. 16.0 13.9 86.8 14.0 11.6 83.0 †

2.1 †2.3

70 years ............. 12.9 10.8 84.2 11.3 9.1 80.1 †

1.5 †1.7

75 years ............. 10.1 8.1 80.2 9.3 6.8 73.1 †

0.8 †1.3

80 years ............. 7.7 5.8 74.8 7.3 5.1 69.1 †

0.4 0.7

Female

5 years ............. 75.0 70.4 93.8 70.1 64.2 91.6 4.9 †

6.1

20 years ............. 60.2 55.6 92.3 55.4 49.6 89.5 †

4.8 †6.0

30 years ............. 50.5 46.0 91.0 46.0 40.2 87.5 †

4.5 †5.7

45 years ............. 36.2 32.0 88.3 32.6 27.1 83.0 †

3.6 †4.9

65 years ............. 18.9 15.3 80.8 17.1 12.4 72.4 †

1.8 †2.9

70 years ............. 15.2 11.7 77.0 13.9 9.6 69.5 †

1.3 †2.1

75 years ............. 11.8 8.4 71.4 11.1 6.8 61.7 †

0.7 †1.6

80 years ............. 8.7 5.5 63.5 8.3 4.4 53.5 †

0.4 †1.1

†Statistically significant (p <0.05). 1ADL refers to activities of daily living; IADL refers to instrumental activities of daily living.

SOURCES: Estimated based on data from the Division of Vital Statistics, National Health Interview Surveys, National Center for Health Statistics; and the U.S. Census Bureau.

Expected Years of Healthy Life Under Various Definitions of Health 39
Table 3.11. Life expectancies and expected years with body mass index less than 30 for selected ages of the white and

black populations, by sex: United States, 1994–96

White Black Difference in years

Years with Years with

Expected BMI1 Expected BMI1 Expected

Expected years less than 30 Expected years with less than 30 Expected years with

years of with BMI1 asa%of life years of BMI1 asa%of life years of BMI1

Sex and age life less than 30 expectancy life less than 30 expectancy life less than 30

Both sexes

20 years ............. 57.5 48.3 83.9 51.5 38.0 73.8 †6.0 †10.2

30 years ............. 48.0 39.9 83.0 42.5 30.8 72.3 †

5.5 †9.1

45 years ............. 34.2 28.2 82.6 29.9 21.3 71.1 †

4.2 †6.9

65 years ............. 17.6 15.2 86.2 15.8 11.8 74.8 †

1.8 †3.4

70 years ............. 14.2 12.4 87.7 12.8 10.1 78.6 †

1.4 †2.4

75 years ............. 11.1 10.0 89.8 10.4 8.4 81.2 †

0.7 †1.5

80 years ............. 8.3 7.6 91.8 8.0 6.7 84.4 †

0.4 †0.9

Male

20 years ............. 54.8 45.8 83.6 47.4 37.7 79.5 †

7.3 †8.1

30 years ............. 45.5 37.6 82.6 38.8 30.6 78.9 †

6.7 †6.9

45 years ............. 32.0 26.4 82.5 26.9 21.2 78.9 †

5.1 †5.1

65 years ............. 16.0 14.1 87.8 14.0 11.7 84.1 †

2.1 †2.3

70 years ............. 12.9 11.5 89.7 11.3 10.0 88.6 †

1.5 †1.5

75 years ............. 10.1 9.3 92.0 9.3 8.4 90.7 †

0.8 †0.9

80 years ............. 7.7 7.3 94.0 7.3 6.9 94.3 †

0.4 †0.4

Female

20 years ............. 60.2 50.8 84.3 55.4 38.4 69.3 †

4.8 †12.4

30 years ............. 50.5 42.1 83.3 46.0 30.9 67.2 †

4.5 †11.2

45 years ............. 36.2 29.9 82.7 32.6 21.3 65.4 †

3.6 †8.6

65 years ............. 18.9 16.1 85.0 17.1 11.8 69.0 †

2.4 †4.3

70 years ............. 15.2 13.1 86.4 13.9 10.1 72.7 †

1.3 †3.0

75 years ............. 11.8 10.4 88.5 11.1 8.4 76.1 †

0.7 †2.0

80 years ............. 8.7 7.9 90.5 8.3 6.7 80.1 †

0.4 †1.2

†Statistically significant (p <0.05). 1BMI refers to body mass index.

SOURCES: Estimated based on data from the Division of Vital Statistics, National Health Interview Surveys, National Center for Health Statistics; and the U.S. Census Bureau.

Table 3.12. Expected years at age 30 and 65 estimated using different definitions of health, by health status: United

States, 1995

At age 30 At age 65

Years not Years not

Healthy Years expected to Healthy Years expected to

Expected years as a expected be healthy Expected years as a expected be healthy

years % of life not to be as % of life years % of life not to be as % of life

Measure in years expectancy healthy expectancy in years expectancy healthy expectancy

Expected years of life ................ 47.5 100.0 0.0 0.0 17.5 100.0 0.0 0.0

Without needing help in ADL1 ........... 43.7 92.0 3.8 8.0 14.9 85.1 2.6 14.9

Able to perform major activity ............ 40.8 85.9 6.7 14.1 14.1 80.6 3.4 19.4

Without needing help in ADL or IADL2 ...... 42.2 88.8 5.3 11.2 13.8 78.9 3.7 21.1

In good or better health ............... 39.0 82.1 8.5 17.9 12.4 70.9 5.1 29.1

Without any activity limitation ............ 35.9 75.6 11.6 24.4 10.7 61.1 6.8 38.9

In excellent health ................... 12.7 26.7 34.8 73.3 2.6 14.9 14.9 85.1

Without chronic diabetes ............... 44.5 93.7 3.0 6.3 15.6 89.1 1.9 10.9

Without heart disease ................ 40.0 84.2 7.5 15.8 12.1 69.1 5.4 30.9

Without hypertension ................. 36.8 77.5 10.7 22.5 10.9 62.3 6.6 37.7

Without chronic arthritis ............... 34.7 73.1 12.8 26.9 8.8 50.3 8.7 49.7

1ADL refers to activities of daily living. 2IADL refers to instrumental activities of daily living.

SOURCES: Estimated based on data from the Division of Vital Statistics, National Health Interview Surveys, National Center for Health Statistics; and the U.S. Census Bureau.

40 Expected Years of Healthy Life Under Various Definitions of Health
Table 3.13. Expected years at age 65 estimated using different definitions of health, by health status and sex:

United States, 1995

Male Female

Years not Years not

Healthy Years expected to Healthy Years expected to

Expected years as a expected be healthy Expected years as a expected be healthy

years % of life not to be as % of life years % of life not to be as % of life

Measure in years expectancy healthy expectancy in years expectancy healthy expectancy

Expected years of life ................ 15.9 100.0 0.0 0.0 18.8 100.0 0.0 0.0

Without needing help in ADL1 ........... 14.9 93.7 1.0 6.3 17.3 92.0 1.5 8.0

Able to perform major activity ............ 14.1 88.7 1.8 11.3 16.8 89.4 2.0 10.6

Without needing help in ADL or IADL2 ...... 13.8 86.8 2.1 13.2 15.1 80.3 3.7 19.7

In good or better health ............... 11.2 70.4 4.7 29.6 13.4 71.3 5.4 28.7

Without any activity limitation ............ 9.9 62.3 6.0 37.7 11.4 60.6 7.4 39.4

In excellent health ................... 2.4 15.1 13.5 84.9 2.8 14.9 16.0 85.1

Without chronic diabetes ............... 14.0 88.1 1.9 11.9 16.9 89.9 1.9 10.1

Without heart disease ................ 10.2 64.2 5.7 35.8 13.6 72.3 5.2 27.7

Without hypertension ................. 10.8 67.9 5.1 32.1 10.9 58.0 7.9 42.0

Without chronic arthritis ............... 9.2 57.9 6.7 42.1 8.4 44.7 10.4 55.3

1ADL refers to activities of daily living. 2IADL refers to instrumental activities of daily living.

SOURCES: Estimated based on data from the Division of Vital Statistics, National Health Interview Surveys, National Center for Health Statistics; and the U.S. Census Bureau.

Table 3.14. Expected years at age 65 estimated using different definitions of health, by health status and race:

United States, 1995

White Black

Years not Years not

Healthy Years expected to Healthy Years expected to

Expected years as a expected be healthy Expected years as a expected be healthy

years % of life not to be as % of life years % of life not to be as % of life

Measure in years expectancy healthy expectancy in years expectancy healthy expectancy

Expected years of life ................ 17.6 100.0 0.0 0.0 15.8 100.0 0.0 0.0

Without needing help in ADL1 ........... 16.4 93.2 1.2 6.8 14.1 89.2 1.7 10.8

Able to perform major activity ............ 15.8 89.8 1.8 10.2 13.1 82.9 2.7 17.1

Without needing help in ADL or IADL2 ...... 14.6 83.0 3.0 17.0 12.1 76.6 3.7 23.4

In good or better health ............... 12.7 72.2 4.9 27.8 9.1 57.6 6.7 42.4

Without any activity limitation ............ 10.9 61.9 6.7 38.1 8.4 53.2 7.4 46.8

In excellent health ................... 2.7 15.3 14.9 84.7 1.5 9.5 14.3 90.5

1ADL refers to activities of daily living. 2IADL refers to instrumental activities of daily living.

SOURCES: Estimated based on data from the Division of Vital Statistics, National Health Interview Surveys, National Center for Health Statistics; and the U.S. Census Bureau.

Expected Years of Healthy Life Under Various Definitions of Health 41
4. Trends in Life Free of Activity Limitation: United States, 1985–95

4.1 Introduction

Trends in the health status of the U.S. population are of 

major interest to researchers, health planners, and policy 

makers. Trends in years gained due to the decline in 

mortality are important, given their effect on other 

health-related issues such as the aging of the population; the 

prevalence of nonfatal chronic conditions; and the 

compression (or expansion) of mortality. The additional 

years gained—caused by the continuous decline of mortality 

observed over the last several decades—might have been 

totally or partially healthy years, depending on the age, sex, 

and socioeconomic status of the population subgroup under 

study. Hence, numerous researchers have focused on trends 

in years gained due to the decline of mortality (especially at 

the older ages) (1–3). 

Conclusions on whether the years gained because of the 

decline in mortality were healthy varied depending on the 

specific health measure used, the period covered, and the 

population subgroups studied. Using data from the NCHS, 

Colvez and Blanchet showed that, between 1966 and 1976, 

the proportion of persons who claimed to have been 

permanently disabled in their major activity rose by 

37 percent. Crimmins and her colleagues, who studied trends 

in disability-free life expectancy between 1970 and 1990, 

concluded that almost all the additional years in life 

expectancy during the 1970s were in disabled years, while 

years gained in the 1980s were years without disability. 

They also noted that, while both males and females gained 

disability-free years in the latter decade, males made larger 

gains than females. A 1989 study on the pattern of change in 

disability and well-being that focused on self-rated health 

and activity level showed a slight decline in physical health 

and an improvement in activity level (4). 

According to these and other health researchers, various 

reasons accounted for the observed changes in disability-free 

or limitation-free life expectancy. Some of the reasons were 

found to be health-related, whereas others were not. In the 

1966–76 period, increases in the incidence of certain 

disorders and the increased use of the health care system 

were among factors that contributed to the 37 percent 

increase in permanent activity limitation (5). A trend study in 

the prevalence of work disability and their correlates in the 

period 1962–84 attributed most of the changes in work 

disability to changes in pathology/impairment-behavior 

factors and change in the age structure of the population (6). 

A study on the effect of eliminating fatal and nonfatal 

diseases on life with or without disability concluded that, 

while eliminating nonfatal diseases such as arthritis and back 

complaints led to the decline of expected life with disability 

(or compression of morbidity), the elimination of fatal 

diseases (such as cancer) suggested the expansion of 

morbidity because it increased both the number of years and 

the proportion of life with disability (7). 

This chapter discusses changes in both life expectancy 

and years free of activity limitation of the U.S. population in 

the period between 1985 and 1995. Activity limitation is 

defined based on the ability of a person to perform a set of 

social roles. A person is assumed to perform a set of social 

roles, and one of these social roles is usually identified as 

his/her major activity. The major activity for a person 5–17 

years of age is going to school, whereas the major activity 

for younger and middle-aged adults is either working or 

keeping house, and the major activity for the elderly 

population is considered to be ADL. Depending on the 

ability of a person to perform the social roles expected of 

his or her age, each person is classified into one of the 

following four categories: not limited; unable to perform 

major activity; limited in kind and/or amount of major 

activity; or limited in other activities (8–10). 

Trends in life expectancy and years free of activity 

limitation will be presented for the white and black 

population subgroups and by sex within each population 

subgroup. Life expectancies for each of the four population 

subgroups will be calculated for each of the 11 years using 

mortality data from NCHS and annual midyear population 

estimates from the U.S. Census Bureau. Age-sex-specific 

activity limitation prevalence rates will be computed based 

on data from NHIS 1985–95. 

4.2 Age-Adjusted Death and Activity

Limitation Rates: United States, 1985–95

Trends in life expectancy and prevalence of activity 

limitation are the major determinants of trends in activity 

limitation-free life expectancy. Trends in life expectancy, in 

turn, are determined by trends in population death rates. 

Hence, the discussion of the dynamics in life free of activity 

limitation over time must start with discussion of trends in 

death rates and activity limitation prevalence rates. The 

age-adjusted death and activity rates for the four population 

subgroups for the period 1985–95 are presented in tables 4.1 

and 4.2. 

Annual death rates (table 4.1) and activity limitation rates 

(table 4.2) are age-adjusted using the U.S. standard million 

population. Each number in the table presents the number of 

deaths per 1,000 resident population. As has already been 

observed by several other NCHS reports (10,11), the 

adjusted rates also indicate that death rates varied by race 

and gender. As expected, white females have the lowest 

adjusted death rates, while black males have the highest 

42 Trends in Life Free of Activity Limitation: United States, 1985–95
rates. The rates for the other subgroups fall between the two 

extremes. The table also shows that mortality has fallen 

between the years 1985 and 1995 for all four population 

subgroups. Decline in mortality continued from 1985 to 

1993, rose slightly in 1993, and continued to fall again after 

that year. The adjusted rates for the year 1993 rose for all 

four population subgroups. Compared to the other three 

population subgroups, white males were the major 

beneficiaries of the decline in mortality in the period. 

Between 1985 and 1995, age-adjusted death rates fell by 

0.84 point for white males, 0.26 point for white females, 

0.38 point for black males, and 0.26 point for black females. 

In the period between 1985 and 1995, observed trends in 

activity limitation rates differed from trends in death rates. 

Between 1985 and 1995, age-adjusted activity limitation 

rates rose slightly for all four groups. Activity limitation 

rates for the black population were higher compared to white 

rates, and for most of the 11 years, adjusted rates for white 

males were higher than white females rates. Within the black 

population, females had higher age-adjusted rates for most of 

the years in the first half of the period, whereas the opposite 

was true for most of the years in the second half. During the 

period, white activity limitation rates rose and fell, with a 

peak in 1993. For the black population, the activity 

limitation rates rose until a peak was reached in 1994, then 

fell. The 1995 activity limitation rates for black males and 

females were lower than their respective 1994 rates. 

4.3 Age-Specific Death and Activity

Limitation Rates: United States,

1985 and 1995

The overall age-adjusted death rates have declined, and 

the overall age-adjusted activity limitation rates have 

increased between 1985 and 1995; however, death rates did 

not decline, and activity limitation rates did not rise, for all 

age groups within the four population subgroups. The 

contribution of changes in age-specific rates to the overall 

changes in mortality and activity limitation could be 

illustrated by comparing 1985 and 1995 age-specific rates 

for each subgroup using the analytic summaries presented in 

tables 4.3 and 4.4 and figures 4.1 through 4.8. 

Between 1985 and 1995, death rates fell for most age 

groups in all four population subgroups. However, there 

were age groups within each of the four population 

subgroups where the observed 1995 death rates were higher 

than the 1985 rates. For white males, 1995 death rates were 

lower than the 1985 rates for all except the three 5-year age 

groups between 30 and 44 years of age. For these three age 

groups, unlike the other 5-year age groups, death rates have 

gone up between 1985 and 1995. The rise in death rates has 

also been observed for white females between 25 and 40 

years of age. 

Between 1985 and 1995, age-specific death rates rose in 

only three 5-year age groups of the white population. On the 

other hand, age-specific death rates rose in many more age 

groups of the black population. For black males, death rates 

fell in half of the 5-year age groups, but death rates rose in 

the other half. Age-specific death rates rose starting with the 

10–14-year age group and continued through the 45–49-year 

age group; these rates also rose through the open-age 

interval of 85 years of age and over. Compared to 1985, 

higher 1995 death rates were observed for black females in 

all 5-year age groups between ages 10 and 44 and for those 

who were 85 years or older. 

The higher 1995 age-specific death rates in the black 

population are different not only in the number of 5-year age 

groups where they occurred, but also in the relative sizes of 

the rates. For any given 5-year age group, the age-specific 

death rate for black males was higher than that for white 

males, and the rate for black females was higher than for 

white females. The impact of the difference in magnitude is 

captured by figures 4.1 through 4.4. For white adults 

Figure 4.1. Number of deaths per 1,000 for white males, by age:

United States, 1985 and 1995

Figure 4.2. Number of deaths per 1,000 for white females, by age:

United States, 1985 and 1995

Trends in Life Free of Activity Limitation: United States, 1985–95 43
between ages 10 and 50 years, the 1995 higher age-specific 

rates were hardly different from the 1985 rates (figures 4.1 

and 4.2). Conversely, for the black population of the same 

ages, the higher 1995 rates were clearly visible, especially 

for black males (figure 4.3). The four figures also clearly 

show that, between 1985 and 1995, mortality has fallen for 

adults between ages 50 and 80. Mortality declined at these 

ages in all four population subgroups, relatively more for 

males than females. 

The 1985 and 1995 age-specific activity limitation 

estimates for the four population subgroups are presented in 

table 4.4. According to the figures in the table, age-specific 

activity limitation rates for 1995 were higher than the 1985 

rates for most of the age groups in the four population 

subgroups. Between 1985 and 1995, activity limitation rates 

for the younger population increased more than for the older 

population. The difference in the 1985 and 1995 activity 

limitation rates by age are presented graphically in 

figures 4.5 through 4.8. For all four population subgroups, 

the 1995 age-specific rates were higher than the 1985 rates 

for the younger ages, and these rates were lower at the older 

ages. Controlling for sex, the observed difference between 

the 1985 and 1995 rates was larger for the black population 

compared to the white. 

Overall, between 1985 and 1995, mortality has declined 

when measured using age-adjusted rates. A comparison of 

the 1985 and 1995 age-specific rates also shows that 

mortality had declined during the period for most 5-year age 

groups, more at the older ages compared to the younger 

ages. On the other hand, between 1985 and 1995, the 

age-adjusted activity limitation rates rose and then declined, 

with the observed peak occurring in 1993 and 1994. The 

1985 and 1995 age-specific activity rates also showed that, 

for most 5-year age groups of all four population subgroups, 

limitation rates were relatively higher in 1995 compared to 

1985. The following paragraphs discuss the combined impact 

Figure 4.3. Number of deaths per 1,000 for black males, by age:

United States, 1985 and 1995

Figure 4.4. Number of deaths per 1,000 for black females, by age:

United States, 1985 and 1995

Figure 4.5. Percentage of white males with activity limitation

from any cause, by age: United States, 1985 and 1995

of these changes in mortality and activity limitation on 

expected years of life free of activity limitation. 

4.4 Years Free of Activity Limitation:

United States, 1985–95

Life expectancy at birth and expected years free of 

activity limitation for the years 1985 through 1995 are 

presented in table 4.5 for white and black males and in 

table 4.6 for white and black females. For each of the four 

population subgroups, the tables also present the percentage 

of remaining life that is expected to be free of activity 

limitation. For males, expectation of life rose continuously 

between 1985 and 1992, fell slightly in 1993, and started to 

rise again after that. During the same period, the trends in 

expected years free of activity limitation for both white and 

black males were less stable than the trends in life 

44 Trends in Life Free of Activity Limitation: United States, 1985–95
Figure 4.6. Percentage of white females with activity limitation

from any cause, by age: United States, 1985 and 1995

expectancy. For white males, expected years free of activity 

limitation at birth, which was 60.5 years in 1985, rose to 

61.4 in 1995. On the other hand, for black males, the 1985 

expected years free of activity limitation at birth was 53.6 

and dropped to 52.9 years in 1995. The proportion of life 

expected to be free of activity limitation has declined 

slightly for both white and black males. In 1985, about 

84.3 percent of a white male baby’s life at birth would be 

expected to be free of activity limitation. By 1995 that 

percentage had dropped by 0.6 percentage point to 

83.7 percent. The percentage of a newly born black male 

baby’s life that would be expected to be free of activity of 

limitation in 1985, on the other hand, was about 82.5. That 

percentage dropped to 81.1 by 1995, resulting in a decline of 

1.4 percentage points. 

Similarly, for females, expectation of life increased 

continuously between 1985 and 1992, declined slightly in 

1993, and rose again after that year. During the period 

1985–95, trends in the expected years free of activity 

limitation for females were unstable. Although the 

differences are small, both white and black females would 

expect to spend more years free of activity limitation in 

1995 compared to 1985. In 1985, white females would 

expect to live 65 years free of activity limitation. In 1995, 

their expected years free of activity limitation had risen to 

65.3 years. In 1985, black females would expect to live 57.6 

years of their future lives free of activity limitation. By 

1995, the expected years free of activity limitation for black 

females had gone up to 57.8 years. 

Although both white and black females would expect to 

live more limitation-free years in 1995 compared to 1985, 

for each group, the percentages of expected life free of 

activity limitation were relatively smaller in 1995 compared 

to 1985. In 1985, a white female would expect to live about 

82.6 percent of her future life free of activity limitation; in 

1995, the percentage dropped to 82, a loss of 0.6 percentage 

point. In 1985, the percentage of life a black female would 

Figure 4.7. Percentage of black males with activity limitation

from any cause, by age: United States, 1985 and 1995

expect to live free of activity limitation was 78.5 percent, 

and that percentage fell to 78.2 in 1995. 

4.5 Gains in Life Expectancy and Expected

Limitation-Free Years: United States,

1985–95

Life expectancy and life free of activity limitation at 

birth, age 20, and 65 in 1985 for each population subgroup 

were compared to life expectancy and life free of activity 

limitation at the same ages in 1995. At the end of the study 

period, each group had a net gain in life expectancy at birth, 

age 20, and 65 (table 4.7). Gains in life expectancy varied 

by race, sex, and age. For white persons, males gained more 

than females at all ages. Black females gained more at birth 

and age 20 than did black males, but at age 65, black males 

gained more expected life than females. 

White male gains in life expectancy were larger than 

gains for black males at all three ages. White and black 

females expected to gain three tenths of a year at age 65. At 

birth and at age 20, white females gained more than black 

females. 

When the difference in the 1985 and 1995 life 

expectancies are measured in absolute terms (in years), the 

gains for white persons of both sexes and for black females 

were larger at the younger ages and smaller at the older 

ages. The life expectancy gain for black males was larger at 

age 65 than at birth or at age 20. On the other hand, when 

the differences are measured in relative terms (difference in 

1985 and 1995 life expectancies as a percentage of the 1985 

life expectancies), gain in life expectancy is larger at age 65 

compared to the younger ages for each of the four groups. 

Between 1985 and 1995, white males, white females, and 

black females expected to gain more activity limitation-free 

time at birth, age 20, and age 65. For these three groups, the 

expected gain in life free of activity limitation varied by age 

Trends in Life Free of Activity Limitation: United States, 1985–95 45
Figure 4.8. Percentage of black females with activity limitation

from any cause, by age: United States, 1985 and 1995

and race. White males expected to gain more than females 

of either race at all the three ages. The expected gain in life 

free of activity limitation was similar at each of the three 

ages for white and black females. The net change in life free 

of activity limitation is different for black males. Black 

males expected to gain activity limitation-free life at age 65. 

At birth and at age 20, they expected to lose all their gains 

in life expectancy to activity limitation. Contrary to the gains 

in life expectancy, the gains in activity limitation-free life 

were larger in the older ages for each of the four groups, 

whether measured in years or as percentage of the expected 

limitation-free years of 1985. 

For each population subgroup, gains in life expectancy 

differed from gains in years free of activity limitation. At 

birth, gains in life expectancy were more than gains in 

activity limitation-free years. For white males, white 

females, and black females, only part of the expected gain in 

life expectancy would be free of activity limitation. For 

black males, the total gain in life expectancy (a meager two 

tenths of a year) was expected to be lost to activity 

limitation (seven-tenths of a year). For white males and 

females of either race, the gain of life expectancy at age 20 

would be partially free of activity limitation, while part 

would be lost to activity limitation. For black males, the 

years gained in life expectancy at age 20 would be totally 

lost to activity limitation. At age 65, gain in life expectancy 

was totally free of activity limitation for each of the four 

population subgroups. 

The changes in life free of activity limitation at baseline 

and the end of the study period were compared using the 

proportion of life expectancy expected to be free of activity 

limitation; the results are presented in figures 4.9 through 

4.12. The figures indicated that for each of the four 

population subgroups, the percentage of life expected to be 

free of activity limitation at birth and age 20 hardly changed 

between 1985 and 1995. The only exception, perhaps, was 

the slight change for black males (figure 4.11). On the other 

53.7 

62.5 

80.3 

79.9 

84.3 

83.7 

0 10 20 30 40 50 60 70 80 90 

65 years 

20 years 

Birth 

Percent 

Age 1995 1985 

Figure 4.9. Expected years free of activity limitation as

percentage of life expectancy, white males: United States, 1985

and 1995

Figure 4.10. Expected years free of activity limitation as

percentage of life expectancy, white females: United States, 1985

and 1995

hand, for each of the four population subgroups, the 

1985 percentage of expected life free of activity limitation at 

age 65 was markedly different from that of 1995. At age 65, 

the percentage of life free of activity limitation rose between 

1985 and 1995 for each of the four population subgroups. 

The percentages rose from 54 to nearly 63 for white males 

(figure 4.9), 59 to 61 for white females (figure 4.10), 52 to 

58 for black males (figure 4.11), and 47 to 50 for black 

females (figure 4.12). 

4.6 Summary

Between 1985 and 1995, life expectancy at birth went up 

for the white as well as the black population. Expected years 

free of activity limitation at birth also increased for white 

46 Trends in Life Free of Activity Limitation: United States, 1985–95
Figure 4.11. Expected years free of activity limitation as

percentage of life expectancy, black males: United States, 1985

and 1995

Figure 4.12. Expected years free of activity limitation as

percentage of life expectancy, black females: United States, 1985

and 1995

males, white females, and black females, but decreased 

slightly for black males. However, when measured as a 

percentage of life expectancy expected years free of activity 

limitation decreased for each of the four subgroups. For 

black males, expected years free of activity limitation 

measured at birth decreased both in absolute terms and as a 

percentage of life expectancy. 

Changes in life expectancy and expected years free of 

activity limitation in the period were also calculated at birth, 

20, and 65 years of age for the white and black populations 

separately by sex. Though differences in the magnitude of 

the increase were noted, life expectancy increased at each of 

the three ages for each of the four population groups. The 

gains in life expectancy measured as a percentage of the 

1985 life expectancy were much higher at age 65 compared 

to the percentage gain at birth or at age 20. 

For the white population, at each of the three ages, the 

percentage gain was larger for males than for females. For 

the black population, the percentage gains at birth and at age 

20 were larger for females than for males; conversely, at age 

65, the percentage gain for males was larger than for 

females. 

For the white population of both sexes and for black 

females, expected years free of activity limitation increased 

at birth, age 20, and age 65. For black males, however, 

expected years free of activity of limitation decreased at 

birth and at age 20, but increased substantially at age 65. 

Just like the gains in life expectancy, for the white 

population, gains in life free of activity limitation were 

larger for males than for females. For the black population, 

gain in expected years free of activity limitation at birth and 

at age 20 was larger for females than for males, but, at age 

65, the gain was larger for males than for females. The gain 

in expected life free of activity limitation at age 65 was 

remarkable for two reasons. First, each of the four groups 

gained in expected life free of activity limitation at this age. 

Second, the gain measured as a percentage of the 1985 

expected years free of activity limitation at age 65 was much 

larger for males than for females both for the black and 

white populations. 

References

1.Verbrugge L. Longer life but worsening health? Trends in 

health mortality of middle-aged and older persons. Milbank 

Q: Health and Society 62:475–519. 1984. 

2.Rogers A, et al. Longer life but worse health measurement 

and dynamics. The Gerontologist 30(5):640–9. 1990. 

3.Crimmins, EM, Saito, Y and Ingegneri, D. Trends and 

disability-free life expectancy in the United States, 1970–90. 

Population and Development Review 23(3):555–72. 1997. 

4.Verbrugge L, Balaban DJ. Patterns of change in disability and 

well-being. Med Care 27(3, supplement):S128–S47. 1989. 

5.Colvet A, Blanchet M. Disability trends in the United States 

population 1966–1976: Analysis of reported causes. Am 

Journal Pub Health 71:464–71. 1981. 

6.Wolfe BL, Haveman R. Trends in the prevalence of work 

disability from 1962 to 1984, and their correlates. Milbank Q 

68(1):53–81. 1990 

7.Nusselder, et al. The elimination of selected chronic diseases 

in a population: The compression and expansion of morbidity. 

Am J Public Health 86(2):187–94. 1996. 

8.Sullivan DF. A single index of mortality and morbidity. 

HSMHA Health Reports, vol 86 no 4. 1971. 

9.Erickson PW, Wilson R, Shannon I. Years of healthy life. 

Statistical Notes, no 7. Hyattsville, Maryland: National Center 

for Health Statistics. 1995. 

10.National Center for Health Statistics. Health, United States, 

1996–1997 and Injury Chartbook. Hyattsville, Maryland. 

1997. 

11. Peters KD, Kochanek KD, Murphy SL. Deaths: Final Data for 

1996: National vital statistics reports; vol 47 no 9. Hyattsville, 

Maryland: National Center for Health Statistics. 1998. 

Trends in Life Free of Activity Limitation: United States, 1985–95 47
Table 4.1. Age-adjusted death rates for all ages, by race and sex: United States, 1985–95

White Black U.S. total

Year Male Female Total Male Female Total Male Female Total

Deaths per 1,000 resident population

1985 .................... 6.94 3.91 5.25 10.54 5.95 7.94 7.23 4.10 5.49

1986 .................... 6.85 3.88 5.20 10.63 5.95 7.97 7.17 4.08 5.45

1987 .................... 6.74 3.85 5.14 10.64 5.93 7.97 7.07 4.05 5.39

1988 .................... 6.74 3.85 5.14 10.91 6.02 8.13 7.09 4.06 5.41

1989 .................... 6.52 3.76 5.00 10.83 5.94 8.06 6.90 3.97 5.28

1990 .................... 6.42 3.69 4.91 10.56 5.79 7.86 6.77 3.89 5.18

1991 .................... 6.34 3.66 4.86 10.51 5.76 7.82 6.70 3.86 5.14

1992 .................... 6.21 3.60 4.77 10.25 5.68 7.66 6.56 3.80 5.04

1993 .................... 6.27 3.68 4.85 10.51 5.79 8.10 6.64 3.88 5.13

1994 .................... 6.17 3.65 4.80 10.29 5.72 7.72 6.53 3.85 5.07

1995 .................... 6.10 3.65 4.76 10.16 5.71 7.66 6.45 3.85 5.03

SOURCE: National Center for Health Statistics. Deaths: Final data for 1985–1995.

Table 4.2. Age-adjusted activity limitation rates from any cause for all ages, by race and sex: United States, 1985–95

White Black U.S. total

Year Male Female Total Male Female Total Male Female Total

Percent with activity limitation

1985 .................... 13.49 12.85 13.19 16.09 16.43 16.36 13.71 13.22 13.50

1986 .................... 13.47 12.99 13.24 15.63 16.59 16.24 13.47 13.24 13.42

1987 .................... 12.85 12.58 12.73 15.48 16.36 16.04 13.00 12.86 12.95

1988 .................... 13.11 12.61 12.90 16.06 16.48 16.36 13.30 12.97 13.12

1989 .................... 13.45 12.84 13.18 16.35 16.34 16.42 13.62 13.07 13.42

1990 .................... 12.82 12.75 12.83 15.26 15.79 15.61 12.95 13.03 13.00

1991 .................... 13.66 13.22 13.42 16.35 15.40 15.91 13.82 13.30 13.56

1992 .................... 14.13 13.76 13.92 17.34 17.21 17.33 14.39 13.99 14.21

1993 .................... 14.67 14.07 14.41 18.02 17.62 17.89 14.86 14.39 14.63

1994 .................... 13.95 13.96 14.01 18.37 17.79 18.10 14.34 14.30 14.36

1995 .................... 13.94 13.36 13.66 17.65 17.16 17.53 14.22 13.64 13.93

SOURCE: National Center for Health Statistics. National Health Interview Survey, 1985–1995.

48 Trends in Life Free of Activity Limitation: United States, 1985–95
Table 4.3. Number of deaths from all causes for the white and black populations, by sex: United States, 1985 and 1995

White males White females Black males Black females

Age 1985 1995 1985 1995 1985 1995 1985 1995

Per 1,000 population

0–4 years .................... 2.60 1.71 1.97 1.36 5.28 3.88 4.32 3.26

5–9 years .................... 0.26 0.20 0.19 0.15 0.40 0.35 0.32 0.26

10–14 years .................. 0.34 0.29 0.20 0.18 0.44 0.46 0.25 0.28

15–19 years .................. 1.12 1.04 0.47 0.44 1.26 2.02 0.45 0.56

20–24 years .................. 1.53 1.39 0.49 0.44 2.22 2.99 0.74 0.85

25–29 years .................. 1.52 1.51 0.53 0.54 2.93 3.55 1.11 1.33

30–34 years .................. 1.66 2.03 0.67 0.73 4.21 4.75 1.67 1.96

35–39 years .................. 2.05 2.53 0.96 1.05 5.42 6.20 2.27 2.77

40–44 years .................. 2.90 3.26 1.54 1.48 7.46 8.40 3.41 3.85

45–49 years .................. 4.61 4.37 2.60 2.28 10.46 11.12 5.26 5.25

50–54 years .................. 7.74 6.59 4.28 3.78 15.75 14.93 8.27 7.43

55–59 years .................. 12.78 10.27 6.75 6.08 22.69 20.19 12.60 10.95

60–64 years .................. 19.90 16.73 10.63 9.83 33.71 29.34 18.30 16.35

65–69 years .................. 30.30 25.71 16.11 15.11 43.76 37.73 24.55 22.61

70–74 years .................. 47.51 39.28 25.18 23.68 62.82 57.49 36.06 35.33

75–79 years .................. 71.51 59.66 40.08 37.59 79.78 74.32 49.99 47.01

80–84 years .................. 109.24 95.71 67.80 62.88 118.03 110.76 79.45 74.86

85 years and over ............... 189.84 177.66 147.55 145.16 157.95 163.19 126.73 133.24

SOURCES: Calculated based on data from the National Vital Statistics System, National Center for Health Statistics; and the U.S. Census Bureau.

Table 4.4. Limitation of activity from any cause for the white and black populations, by sex: United States, 1985 and 1995

White males White females Black males Black females

Age 1985 1995 1985 1995 1985 1995 1985 1995

Percent of population

0–4 years .................... 2.49 3.37 1.37 1.94 3.99 4.06 2.34 2.69

5–9 years .................... 6.63 8.01 4.90 4.31 9.00 9.43 4.33 6.44

10–14 years .................. 7.35 9.68 5.23 5.52 8.99 12.02 6.04 7.69

15–19 years .................. 7.17 8.52 5.44 7.62 5.27 9.20 5.62 7.43

20–24 years .................. 6.35 6.49 5.13 6.90 5.22 10.39 4.84 7.01

25–29 years .................. 7.27 8.76 6.38 7.46 7.58 9.58 6.28 9.09

30–34 years .................. 9.87 8.70 8.56 10.14 10.56 14.47 10.38 10.90

35–39 years .................. 11.38 11.49 10.12 11.82 13.64 16.65 12.47 12.20

40–44 years .................. 11.81 13.49 12.67 13.49 11.33 19.05 18.65 17.71

45–49 years .................. 12.52 16.03 15.50 17.08 23.29 19.23 19.59 22.14

50–54 years .................. 18.96 19.53 18.47 21.92 26.13 30.68 27.78 30.96

55–59 years .................. 24.69 23.47 25.32 26.60 29.62 29.88 35.35 38.09

60–64 years .................. 32.85 30.50 32.69 28.74 37.13 38.38 50.58 43.71

65–69 years .................. 40.71 36.72 36.42 33.18 46.87 49.19 53.63 56.48

70–74 years .................. 32.46 31.48 32.67 28.43 48.22 35.77 42.77 30.88

75–79 years .................. 35.82 36.36 39.33 34.50 44.05 38.08 37.86 49.63

80–84 years .................. 43.56 40.33 46.03 46.29 49.16 31.52 66.54 57.76

85 years and over ............... 52.94 50.04 56.82 60.35 63.03 53.60 76.96 59.53

SOURCE: Calculated based on data from the 1985 and 1995 National Health Interview Surveys, National Center for Health Statistics.

Trends in Life Free of Activity Limitation: United States, 1985–95 49
Table 4.5. Life expectancy and expected years free of any activity limitation for males at birth, by race: United States,

1985–95

White Black U.S. total

Expected Years free Expected Years free Expected Years free

years of activity years of activity years of activity

free of limitation free of limitation free of limitation

Life activity as % of life Life activity as % of life Life activity as % of life

Year expectancy limitation expectancy expectancy limitation expectancy expectancy limitation expectancy

1985 ............. 71.8 60.5 84.3 65.0 53.6 82.5 71.3 59.8 83.9

1986 ............. 71.9 60.7 84.4 64.8 53.7 82.9 71.2 60.1 84.4

1987 ............. 72.1 61.3 85.0 64.7 53.7 83.0 71.4 60.5 84.7

1988 ............. 72.2 61.2 84.8 64.4 53.0 82.3 71.4 60.3 84.5

1989 ............. 72.5 61.1 84.3 64.3 52.9 82.3 71.7 60.2 84.0

1990 ............. 72.7 61.7 84.9 64.5 53.9 83.6 71.8 60.9 84.8

1991 ............. 72.9 61.2 84.0 64.6 53.2 82.4 72.0 60.4 83.9

1992 ............. 73.2 60.7 82.9 65.0 52.2 80.3 72.3 60.3 83.4

1993 ............. 73.1 60.6 82.9 64.6 52.1 80.7 72.2 59.8 82.8

1994 ............. 73.3 61.3 83.6 64.9 52.1 80.3 72.4 60.3 83.3

1995 ............. 73.4 61.4 83.7 65.2 52.9 81.1 72.5 60.5 83.4

SOURCES: Estimated based on data from the National Vital Statistics System, National Health Interview Surveys, National Center for Health Statistics; and the U.S. Census Bureau.

Table 4.6. Life expectancy and expected years free of any activity limitation for females at birth, by race: United States,

1985–95

White Black U.S. total

Year

Life

expectancy

Expected Years free Expected Years free Expected Years free

years of activity years of activity years of activity

free of limitation free of limitation free of limitation

activity as % of life activity as % of life activity as % of life

limitation expectancy limitation expectancy limitation expectancy

Life

expectancy

Life

expectancy

1985 ............. 78.7 65.0 82.6 73.4 57.6 78.5 78.2 64.2 82.1

1986 ............. 78.8 64.9 82.4 73.4 57.7 78.6 78.2 64.2 82.1

1987 ............. 78.9 65.5 83.0 73.4 57.9 78.9 78.3 64.8 82.8

1988 ............. 78.9 65.6 83.1 73.2 57.7 78.8 78.3 64.8 82.8

1989 ............. 79.2 65.4 82.6 73.3 57.8 78.9 78.5 64.6 82.3

1990 ............. 79.4 65.6 82.6 73.6 58.7 79.8 78.8 64.8 82.2

1991 ............. 79.6 65.3 82.0 73.8 59.1 80.1 78.9 64.7 82.0

1992 ............. 79.8 64.8 81.2 73.9 57.4 77.7 79.1 64.0 80.9

1993 ............. 79.5 64.6 81.3 73.7 57.4 77.9 78.8 63.8 81.0

1994 ............. 79.6 64.8 81.4 73.9 57.4 77.7 79.0 64.0 81.0

1995 ............. 79.6 65.3 82.0 73.9 57.8 78.2 78.9 64.6 81.9

SOURCES: Estimated based on data from the National Vital Statistics System, National Health Interview Surveys, National Center for Health Statistics; and the U.S. Census Bureau.

50 Trends in Life Free of Activity Limitation: United States, 1985–95
Table 4.7. Life expectancy and expected years free of any limitation at birth, age 20, and age 65 for the white and black

populations, by sex: United States, 1985 and 1995

Life expectancy

Difference between 1985 and 1995

in life expectancy

Years free of

activity limitation

Difference between 1985 and 1995

in limitation-free years

As % of 1985

limitation-free

Race, sex, and age 1985 1995 In years years

As % of 1985

life expectancy 1985 1995 In years

White males

Birth .................. 71.8 73.4 1.6 2.2 60.5 61.4 0.9 1.5

20 years ................ 53.4 54.8 1.4 2.6 42.9 43.8 0.9 2.1

65 years ................ 14.9 16.0 1.1 7.4 8.0 10.0 2.0 25.0

White females

Birth .................. 78.7 79.6 0.9 1.1 65.0 65.3 0.3 0.5

20 years ................ 59.7 60.3 0.6 1.0 46.7 47.0 0.3 0.6

65 years ................ 18.6 18.9 0.3 1.6 11.0 11.6 0.6 5.5

Black males

Birth .................. 65.0 65.2 0.2 0.3 53.6 52.9 –0.7 –1.3

20 years ................ 47.2 47.4 0.2 0.4 36.8 36.2 –0.6 –1.6

65 years ................ 13.2 14.0 0.8 6.1 6.8 8.1 1.3 19.1

Black females

Birth .................. 73.4 73.9 0.5 0.7 57.6 57.8 0.2 0.3

20 years ................ 55.1 55.4 0.3 0.5 40.0 40.2 0.2 0.5

65 years ................ 16.8 17.1 0.3 1.8 7.9 8.6 0.7 8.9

SOURCES: Estimated based on data from the National Vital Statistics System, National Health Interview Surveys, National Center for Health Statistics; and the U.S. Census Bureau.

Trends in Life Free of Activity Limitation: United States, 1985–95 51
5. The Impact of Incomplete Data on Healthy Life Expectancy Estimates

5.1 Introduction

Data for the two components of summary measure of 

health come from different data sources. Mortality data come 

from vital records collected by States, the District of 

Columbia, and Territories, on all deaths occurring in those 

jurisdictions (1). Sources for morbidity data include 

administrative record surveys, such as hospital discharge and 

medical office records, interview surveys, and examination 

surveys. Surveys generally do not evaluate all segments of 

the population. For instance, household interview surveys 

generally do not include institutionalized populations; 

telephone interview surveys do not include people without 

access to a telephone; school-based surveys do not include 

children who have dropped out of school; medical office 

record surveys do not include people seeking medical help 

from emergency rooms; and hospital discharge surveys do 

not include ambulatory surgery patients. Consequently, the 

population on which death records are obtained is not often 

the same as the population included in a survey. There is 

substantial overlap, but the populations are not identical. 

Because household surveys are commonly used to obtain 

health information, the purpose of this chapter is to evaluate 

which subgroups of the population are excluded from most 

of these surveys; obtain data on those subgroups; and 

determine the impact on estimates of summary measures of 

health including whether additional data in the morbidity 

component are considered. 

Data from NHIS will be considered as the data source on 

the noninstitutionalized population for measures of morbidity 

included in a summary measure (2). NHIS is a survey of the 

community-dwelling population that does not include the 

institutional population. This means that health 

circumstances of this portion of the population would not be 

included in morbidity measures derived from the NHIS. The 

deaths of the institutional population, however, are included 

in national vital statistics data. If the health status of the 

institutional population were identical to that of the 

community-dwelling population, the summary measures 

constructed from the community-dwelling survey would not 

be biased. To the extent that the institutional population’s 

health differs from that of the noninstitutionalized 

population, the summary measures will not accurately 

characterize the health status of the total population, and 

trends over time could be affected by changes in the 

institutional rates. 

According to the 1990 census, about 97.3 percent of the 

population of the United States were community dwellers 

(table C). Of the remaining 2.7 percent of the population, 

about 1.3 percent were institutionalized, and about 

1.4 percent of the population was neither community 

dwellers nor institutionalized. The last group included 

persons who were in dormitories, military quarters, shelters, 

group homes, crews of maritime vessels, staff residents of 

institutions, residents of living quarters for victims of 

disasters, and populations of other similar settings (3). 

These three groups (the community dwellers, the 

institutionalized, and other) are comprised of persons of very 

different ages, and the age structure of any one of the three 

groups does not represent that of the total population. In 

addition, those in nursing homes and long-term care facilities 

clearly have different health status from the 

community-dwelling population of the same age. Because of 

the lower socioeconomic status of the population in 

correctional facilities and the high use of drugs and alcohol 

among inmates, the health status of the incarcerated 

population would be expected to be worse than the health 

status of the general population of the same age. The health 

status of those in the military probably does not differ 

substantially from the health status of the communitydwelling population. Because physical ability is a 

requirement for entry into the military and poor health 

conditions may often result in discharge, this group may 

even be healthier than the noninstitutionalized civilian 

population. 

Table C. The community and institutionalized population, by sex: United States, 1990

Type of residence Both sexes Male Female

Total ................................ 248,709,873 121,239,418 127,470,455

Community ............................ 242,012,129 117,450,800 124,561,329

Institutions ............................ 3,334,018 1,801,352 1,532,666

Nursing homes ........................ 1,772,032 493,609 1,278,423

Correctional institutions ................... 1,115,111 1,030,207 84,904

Other institutions ....................... 446,875 227,536 169,339

Other ................................ 3,363,726 1,987,266 1,376,460

SOURCE: U.S. Census Bureau. 1990 Census of the population: General population characteristics, November 1992.

52 The Impact of Incomplete Data on Healthy Life Expectancy Estimates
Table D. Percentage distribution of the noninstitutionalized and institutionalized population, by broad age group:

United States, 1990

Institutionalized

Age Noninstitutionalized Nursing home Prison Military

0–14 years ............................ 22.14 0.00 0.00 0.00

15–64 years ........................... 65.74 10.23 99.32 99.99

65 years and over ........................ 12.12 89.77 0.68 0.01

SOURCE: U.S. Census Bureau. 1990 Census of the population: General population characteristics, November 1992.

In 1990, about half of the institutional population resided 

in nursing homes or long-term care facilities; one third were 

residents in correctional institutions. In addition to the 

nursing home population, the military, and the population in 

correctional institutions, the institutionalized population 

included those who were in hospital wards; schools for the 

mentally retarded or physically handicapped; those who had 

no usual homes elsewhere; and those who were in juvenile 

institutions. 

About 5 percent of the population 65 years of age and older 

was living in institutions in 1990. The percentage is even higher 

in the oldest ages (24.5 percent among those 85 years and 

over). Older women are more likely than older men to be 

institutionalized (16.3 percent for men 85 years and over, and 

27.7 percent for women in the same age group) (3). 

The age distribution of the noninstitutionalized civilian 

population (also referred to as community dwellers) and the 

institutionalized populations in the nursing homes, local, 

State and Federal penitentiaries and those who are in the 

military is presented in table D. While about one out of 

every five community dwellers is younger than age 15, none 

of the three institutions has a measurable proportion of the 

population younger than age 15. A large segment of the 

community dwellers and almost all of the institutionalized 

population in prison and the military fall in the broad 15–64 

year age group. 

Only a small fraction of the nursing home population is 

younger than age 65. The distribution shows that nearly 

90 percent of the nursing home population is older than age 

65. Unlike the distributions of the noninstitutionalized 

civilian population or the other segments of the 

institutionalized population, the nursing home population 

distribution is also strongly skewed in favor of females, with 

nearly 260 females for every 100 males (table C). The 

observed differentials in age structure and sex composition, 

especially between the community dwellers and the nursing 

home population, is significant because health disparities 

have been shown to exist between such populations because 

of age and sex composition, even when controlling for all 

other factors that positively or negatively impact 

health (4–7). 

5.2 The 1995 Noninstitutionalized Civilian

and Institutionalized Populations

According to the 1995 NHIS, the civilian 

noninstitutionalized population of the United States was 

estimated to be 261,902,900, of which 127,576,500 were 

males and 134,326,400 were females. During the same 

survey year, 1,548,600 persons resided in nursing homes 

with three or more beds. Of the total nursing home 

population, only 422,300 were males, whereas 1,126,200 

were females. The gender distributions for the groups of 

population indicate that, for persons 75 to 84 years of age, 

there were about 95 males for every 100 females in the 

community-dwelling population, but there were fewer than 

40 males per 100 females among the nursing home 

population (table E). The last two columns of the table also 

show that the sex ratio of both population subgroups 

declines with age, with the sex ratio of the nursing home 

population declining much faster than that of the community 

dwellers. The two population subgroups are significantly 

different with regard to their age distribution. 

While more than 80 percent of the community-dwelling 

population was younger than age 64, less than 20 percent of 

the nursing home population was younger than age 64. 

Table E. Percentage distribution and sex ratio of community dwellers and the nursing home population, by broad age

group: United States, 1995

Age distribution Sex ratio

Age Community Nursing home Community Nursing home

0–64 years ............................ 89.7 15.3 98.7 108.0

65–74 years ........................... 6.5 18.7 80.4 72.2

75–84 years ........................... 3.1 34.3 64.9 39.9

85 years and over ........................ 0.7 31.7 95.0 22.5

All ages .............................. 100.0 100.0 95.0 37.5

NOTE: Sex ratio is defined as the number of males per 100 females.

SOURCE: National Center for Health Statistics. National Health Interview Survey, 1995; National Nursing Home Survey, 1995.

The Impact of Incomplete Data on Healthy Life Expectancy Estimates 53
Figure 5.1. Percentage of the female population 65 years of age and over who need help with at least one activity of daily living, by age

and residence: United States, 1995

5.2.1 The noninstitutionalized civilian population

About 12 percent of the 1995 noninstitutionalized civilian 

population was 65 years of age or older. Only 1 out of every 

10 noninstitutionalized civilian males was 65 years or older, 

whereas nearly 14 percent of community-dwelling females 

were 65 years or older (table 5.1). In 1995, only 5.0 percent 

of the noninstitutionalized civilian population was 75 years 

or older (3.8 percent for males and 6.0 percent for females). 

The segment of the population 85 years of age or over 

accounted for 1.1 percent (0.7 percent for males and 

1.4 percent for females). 

With 92.2 percent younger than age 65, the black 

population was relatively younger compared to the white 

population. Only 87.1 percent of the white population was 

younger than age 65. In 1995, nearly 6 out of every 100 

white, noninstitutionalized civilian persons were 75 years of 

age or older. On the other hand, only about 3 out of 100 

members of the black, noninstitutionalized civilian 

population belonged to the age group 75 years or older. Only 

1.2 percent of whites and 0.6 percent of blacks were 

members of the age groups commonly referred to as the 

oldest old. 

5.2.2 The 1995 nursing home population

Table 5.2 provides data on the 1995 nursing home 

population. In 1995, slightly more than one and a half 

million persons resided in nursing homes. The residents were 

predominantly female. Male residents accounted for only 

27.3 percent of the total residents. About 88.3 percent were 

white, and 9.6 percent were black. Only 8 percent of the 

nursing home population was younger than 65 years. The 

remaining 92 percent of the nursing home population was 65 

years and older. More than half of the nursing home 

population aged 65 years and over was 85 years or older. Of 

the total 1995 nursing home population, 46.7 percent 

(31.6 percent for males and 52.4 percent for females) was in 

the oldest old age group. 

The distribution of the nursing home population by age 

and race shows that 93 percent of the white and nearly 

83 percent of the black nursing home population were 65 

years and older. While nearly 49 percent of the white nursing 

home residents were 85 years of age and over, less than 

31 percent of the black nursing home residents belonged to 

this age group. Finally, compared to the 1995 

noninstitutionalized civilian population, the 1995 nursing 

home population was much older, mainly white, and 

predominantly female. 

5.3 Functional Limitation: The Community

and Nursing Home Populations

Data on the functioning status of the community and the 

nursing home population of 1995 are presented in table 5.3. 

54 The Impact of Incomplete Data on Healthy Life Expectancy Estimates
Figure 5.2. Percentage of the female population 65 years of age and over who need help with at least one instrumental activity of daily

living, by age and residence: United States, 1995

Data presented in the top half of the table are the percentage 

of the population having limitation in at least one ADL. In 

addition to those with at least one ADL, the table also shows 

the proportion of the community and nursing home 

populations needing help with at least one ADL or IADL. 

ADL limitation is defined in terms of the resident’s need for 

the help of another person. Instrumental activities of daily 

living include the four daily tasks: taking care of personal 

possessions; handling money; securing personal items; and 

using the telephone. IADL limitation is defined based on the 

residents’s need for assistance or supervision in performing 

these activities. Expected years free of activity limitation 

were estimated using indicators of the need for the help of 

another person. 

5.3.1 Functional limitation: The population

5 years of age and over

The data in table 5.3 show the magnitude of the 

difference between the prevalence rates of functional 

limitation in the community and nursing home population, a 

clear reflection of the role of nursing homes in providing 

care. According to the data, about 96 percent (93.9 percent 

for males and 97.0 percent for females) of the nursing home 

population would be considered limited in at least one ADL. 

The percentage of the nursing home population that needs 

help in at least one ADL or IADL rises to 98.4 percent (97.8 

for males and 98.6 percent for females). 

Age-adjusted prevalence rates show that, compared to the 

nursing home population, the community-dwelling 

population is almost free of ADL limitations. The adjusted 

prevalence rates of ADL limitation for this population is 

only 1 percent compared to 89.2 percent (86.1 for males and 

92.5 percent for females) for the nursing home residents. A 

similar difference between age-adjusted prevalence rates of 

functional limitations is also observed when the adjusted 

rates are measured based on needing help in at least one 

ADL or IADL. The adjusted rate for the community 

population that needs help in at least one ADL or IADL is 

less than 3 percent. On the other hand, the adjusted 

prevalence rate for the nursing home residents is nearly 

97 percent (95.9 for males and 98.0 percent for females). 

According to the 1995 National Nursing Home Survey, 

personal care was provided to 91 percent of the residents 65 

years of age and over in nursing homes to assist the 

residents with at least one ADL (8). The age-sex-specific 

rates by 5-year age group for the 1995 community and 

institutional populations needing help with at least one ADL 

are shown in table 5.4, and the rates for those needing help 

with at least one ADL or IADL are presented in table 5.5. 

The Impact of Incomplete Data on Healthy Life Expectancy Estimates 55
Figure 5.3. Percentage of the female population 65 years of age and over who need help with at least one activity of daily living, by age

and residence: United States, 1995

5.3.2 Functional limitation: The population

65 years of age and over

Figures 5.1 and 5.2 show the differences in the 

prevalence rates of limitations between female 

community-dwelling and nursing home populations by 

5-year age group. Figure 5.1 presents the age-specific 

difference in the prevalence of ADL-only limitation. 

Figure 5.2 presents the difference in limitations due to at 

least one IADL. Both figures indicate that limitations are 

relatively very low in the younger ages and increase 

continuously with age. The two figures also indicate that a 

clearly visible difference in activity limitations for the two 

population subgroups emerge starting at around 65 years of 

age. The data seem to suggest the presence of a strong 

positive correlation between ADL limitations and age, 

especially after age 65. After age 65, not only are the 

differences between the two subgroups visible, but they tend 

to increase with age at a relatively faster rate. 

The relative differences in the prevalence rates for 

females aged 65 and over are presented in figures 5.3 and 

5.4. According to figure 5.3, the prevalence rate of limitation 

in at least one ADL for community-dwelling females rises 

from 2.6 percent for the 65–69 year age group to about 

20 percent for those who are 85 years or over. On the other 

hand, when ADL data for community-dwelling females are 

combined with ADL data for female nursing home residents, 

the percentage rises from 3.3 for the 65–69 year age group 

to 38.4 for those who are 85 years and over. 

Figure 5.4 also shows differences in the age-specific rates 

of the two populations. Compared to the group differences 

observed in figure 5.3, the group differences in limitation in 

ADL or IADL for corresponding age groups tend to be 

smaller. For community-dwelling females, the prevalence of 

at least one ADL or IADL limitation rises from 9 percent for 

those in the 65–69 year age group to 45.4 percent for those 

who are 85 years of age or over. The corresponding 

percentages for females residing in nursing homes and 

female community dwellers combined are 9.7 at the younger 

age group and 58 at the older age group. 

The four figures suggest that the female nursing home 

resident data’s contribution to the variation in the estimation 

of functional limitations differs by age. The contribution is 

negligible at the younger ages but becomes substantially 

larger at the older ages, starting around 65 years of age. This 

is mainly because the nursing population is predominantly 

old. After age 65, the contribution to the difference in 

age-specific rates increases more steeply, whether the 

prevalence rates are measured based on ADL alone or on the 

ADL or IADL combination. 

Such differences in functional limitation rates for 

population subgroups have an impact on the estimation of 

summary measures of health that use these rates as partial 

inputs or components of the overall estimated summary 

measure. In the next section, DFLE estimates will be used to 

demonstrate how including or excluding data on a segment 

of a population will affect the overall estimated value of a 

summary measure of health. Since separate mortality data 

for each population group are not available, the same life 

table will be used for each of the two population subgroups. 

It is important to note that a slight difference between the 

levels of mortality of the two subgroups may exist because 

of the difference in age and sex composition of the 

population subgroups. Healthy life expectancy is a summary 

56 The Impact of Incomplete Data on Healthy Life Expectancy Estimates
Figure 5.4. Percentage of the female population 65 years of age and over who need help with at least one activity of daily living or

instrumental activity of daily living, by age and residence: United States, 1995

measure derived based on a mortality and morbidity (activity

or functional limitation) components. Since the same level of

mortality is assumed for both population subgroups, any

observed difference in the estimated summary measures with

and without the nursing home population data will be due to

differences in the functional limitations of the two

population subgroups.

5.4 Effect on Healthy Life Expectancy

Estimates for the Older Population

Estimated life expectancies and HLEs for females in 

1995 at selected ages are presented in table 5.6. Four sets of 

healthy life expectancies were estimated. The first two sets 

of healthy life expectancies were estimated using 

age-specific prevalence rates of limitation in at least one 

ADL. One set of HLEs is estimated for only female 

community dwellers. A second set of HLEs were estimated 

combining the data for females community dwellers and 

female nursing home residents. Two more sets of HLEs were 

estimated (one for female community residents and a second 

for the two female population subgroups combined) using 

prevalence rates of functional limitation in ADL or IADL. 

The results are presented in the last two columns. 

On average, a female who was 65 years of age in 1995 

would expect to live 18.8 more years, or to the age of 83.8 

years. On the other hand an 80-year-old female would 

expect to live 8.7 more years. Since the same level of 

mortality level is assumed for females residing in the 

community and in nursing homes, the estimated life 

expectancies in the second column of table 5.6 apply to both 

groups. Life expectancies could not be estimated for the two 

groups separately because of data constraints. On the other 

hand, available data has made it possible to estimate HLEs 

for the female community population (based only on the 

population subgroup’s health status data) and the combined 

health expectancies for the two subgroups (based on pooled 

health status data). Estimating HLE with and without the 

female nursing home population health data makes a 

relatively large difference. The differences between the two 

estimates in years and percentages are given in the fifth and 

sixth columns. 

Estimated healthy years differ by nine-tenths of a year at 

age 65, by as much as one year at 70 and 75 years of age, 

and by more than 1 year (1.1 year) at 80 years of age and 

over. In terms of percentages, excluding nursing home 

population health data results in the overestimation of HLE 

at 65 years of age by more than 5 percent. The percentage of 

overestimation rises with age, relatively slowly at first, but 

very sharply at the older ages, reaching almost 23 percent at 

80 years of age and over. 

Healthy life expectancies with and without female 

nursing home resident data were estimated using data on 

activity limitation of ADL or IADL. The estimates and the 

differences (in years and percent) are presented in the last 

four columns of table 5.6. The differences between estimates 

with and without female nursing home population health 

data are very similar to the differences observed between 

estimates calculated based on functional limitation due to 

ADL only. When limitation in at least one ADL or IADL is 

used as the basis to differentiate health states, estimating 

HLE with and without female nursing home population 

health data differs from seven-tenths of a year at age 65 to 

eight-tenths of a year at 85 years of age and over. In terms 

The Impact of Incomplete Data on Healthy Life Expectancy Estimates 57
of percentages, overestimation of HLE ranges from 

4.7 percent at age 65 to 24.2 percent at 85 years of age and 

over. 

A z-score was constructed to test whether the 

age-specific differences between HLEs estimated with and 

without female nursing home population data were 

statistically significant. The statistical tests indicate that, 

regardless of the health status measure used to differentiate 

healthy and unhealthy states, excluding nursing home 

population health data results in a significantly different 

HLE estimate from one that includes nursing home 

population health data. 

Another institutional population group that may affect the 

estimation of HLE of the total population is the population 

in correctional facilities. In 1990, more than one third of the 

institutional population (1.1 million or 33.4 percent of the 

institutional population) resided in Federal and State prisons 

(table C). Of a total of 1.1 million, more than 1 million 

were males, and about 85,000 were females (9). By 1995, 

the total population in correctional facilities rose to 1.6 

million; about 1.5 million were males, while only about 

115,000 were females. About 748,000 were white, and 

676,000 were black (10). Detailed data on the health status 

of this population group were not available to estimate 

expected years of healthy life including or not including 

health data on this population group. It should be noted that, 

to the extent that the health status of this and other similar 

population subgroups differs from the health status of the 

noninstitutionalized civilian population covered by NHIS, a 

variation should be expected between estimates of HLEs 

estimated for the total population with and without data on 

any one of these and other population groups. 

References

1.National Center for Health Statistics. Vital statistics of the 

United States, 1992, vol II, mortality, part A. Washington, 

D.C.: Public Health Service. 1996. 

2.Benson V, Marano MA. Current estimates from the National 

Health Interview Survey, 1995. Vital Health Stat 10(199). 

Hyattsville, Maryland: National Center for Health Statistics. 

1998. 

3.U.S. Census Bureau. United States summary 1990: General 

population characteristics. Washington D.C.: U.S. Government 

Printing Office. November 1992. 

4.Kaplan RM, Anderson JP, Wingard DL. Gender differences in 

health-related quality of life. Health Psychology 10(2):86–93. 

1991. 

5.Manton KG. Population models and gender differences in 

mortality, morbidity and disability risks. In M Ory and H. 

Warner (eds.) Gender, health and longevity: Multidisciplinary 

perspectives. New York: Springer. 1990. 

6.Verbrugge LM, Lepkowski JM, Imanaka Y. Comorbidity and 

its impact on disability. Milbank Q 67(3–4):450–84. 1989. 

7.Wagener DK, Molla MT, Crimmins EM, Pamuk E, Madans 

JH. Summary measures of population health: Addressing the 

first goal of Healthy People 2010, improving health 

expectancy. Statistical Notes, no 22. Hyattsville, Maryland: 

National Center for Health Statistics. September 2001. 

8.Gabrel C, Adrienne J. The national nursing home survey: 

1995 summary. National Center for Health Statistics. Vital 

Health Stat 13 (146). 2000. 

9.Gilliard DK, Beck AJ. Prison and jail inmates, 1995. Bureau 

of Justice Statistics Bulletin, U.S. Department of Justice, 

Office of Justice Programs, p. 1. August 1996. 

10.Bureau of Justice Statistics. Correctional population in the 

United States, 1995. U.S. Department of Justice, Office of 

Justice Programs, p. 12. June 1997. 

58 The Impact of Incomplete Data on Healthy Life Expectancy Estimates
Table 5.1. Number and percentage distribution of community residents by sex and race, according to age at interview:

United States, 1995

Sex Race

Age at interview All residents Males Females White Black

Number

All ages .............................. 261,902,900 127,576,500 134,326,400 217,206,800 32,754,600

Under 65 years ......................... 230,436,500 114,437,000 115,999,500 189,104,200 30,214,400

65–74 years ........................... 18,461,400 8,228,800 10,232,600 16,259,000 1,684,000

75–84 years ........................... 10,191,500 4,009,400 6,182,100 9,273,000 672,500

85 years and over 2,813,500 901,300 1,912,200 2,570,600 183,700

Percent distribution

All ages .............................. 100.0 100.0 100.0 100.0 100.0

Under 65 years ......................... 88.0 89.7 86.4 87.1 92.2

65–74 years ........................... 7.0 6.5 7.6 7.5 5.1

75–84 years ........................... 3.9 3.1 4.6 4.3 2.1

85 years and over ........................ 1.1 0.7 1.4 1.2 0.6

SOURCE: National Center for Health Statistics. National Health Interview Survey.

Table 5.2. Number and percentage distribution of nursing home residents by sex and race, according to age at interview:

United States, 1995

Sex Race

Age at interview All residents Males Females White Black

Number

All ages .............................. 1,548,600 422,300 1,126,200 1,367,200 148,400

Under 65 years ......................... 124,500 64,800 59,700 94,700 25,400

65–74 years ........................... 189,700 79,500 110,300 154,100 29,600

75–84 years ........................... 509,600 144,300 365,400 451,300 47,500

85 years and over ........................ 723,500 133,300 590,200 666,200 45,800

Percent distribution

All ages .............................. 100.0 100.0 100.0 100.0 100.0

Under 65 years ......................... 8.0 15.3 5.3 6.9 17.1

65–74 years ........................... 12.3 18.8 9.8 11.3 20.0

75–84 years ........................... 32.9 34.2 32.4 33.0 32.0

85 years and over ........................ 46.7 31.6 52.4 48.7 30.9

SOURCE: National Center for Health Statistics. National Health Interview Survey.

The Impact of Incomplete Data on Healthy Life Expectancy Estimates 59
Table 5.3. Percentage of population needing help with at least one activity of daily living and needing help with at least

one activity of daily living or instrumental activity of daily living, by broad age group, sex, and place of residence:

United States, 1995

Age (in years)

Type of assistance

and population Less than 65 65–74 75–84 85 and over 5 and over Age adjusted

Need personal help with ADL1 Percent

Community population

All persons ........................... 0.7 3.2 8.1 18.8 1.4 1.0

Males .............................. 0.7 3.3 7.5 16.0 1.2 1.0

Females ............................ 0.7 3.2 8.5 20.0 1.6 1.0

Nursing home population

All persons ........................... 88.7 94.8 96.8 97.3 96.1 89.2

Males .............................. 85.5 93.3 96.5 95.5 93.9 86.1

Females ............................ 92.2 95.9 96.9 97.7 97.0 92.5

Need help with ADL or IADL2

Community population

All persons ........................... 2.0 9.1 19.4 41.8 3.8 2.8

Males .............................. 1.7 7.8 15.3 34.2 2.9 2.3

Females ............................ 2.3 10.1 22.1 45.4 4.6 3.1

Nursing home population

All persons ........................... 96.8 98.1 98.5 98.6 98.4 96.9

Males .............................. 95.7 98.7 98.7 97.4 97.8 85.9

Females ............................ 98.0 97.6 98.5 98.8 98.6 98.0

1ADL refers to activity of daily living. 2IADL refers to instrumental activity of daily living.

SOURCE: National Center for Health Statistics. National Health Interview Survey (community), National Nursing Home Survey (nursing home residents), and Division of Vital Statistics.

Table 5.4. Percentage of population needing help with at least one activity of daily living, by age, sex, and place of

residence: United States, 1995

Community residents only Community and nursing home residents

Age Male Female Total Male Female Total

5–9 years ............................. 0.66 0.35 0.51 0.67 0.35 0.51

10–14 years ........................... 0.57 0.24 0.41 0.57 0.24 0.41

15–19 years ........................... 0.26 0.17 0.22 0.27 0.17 0.22

20–24 years ........................... 0.37 0.43 0.40 0.38 0.44 0.41

25–29 years ........................... 0.21 0.27 0.24 0.22 0.29 0.25

30–34 years ........................... 0.56 0.41 0.48 0.59 0.42 0.50

35–39 years ........................... 0.62 0.64 0.63 0.66 0.66 0.66

40–44 years ........................... 0.62 0.91 0.77 0.67 0.95 0.81

45–49 years ........................... 0.81 0.65 0.73 0.86 0.73 0.80

50–54 years ........................... 1.28 1.28 1.28 1.38 1.39 1.39

55–59 years ........................... 1.65 1.64 1.64 1.84 1.82 1.83

60–64 years ........................... 2.46 2.47 2.46 2.85 2.89 2.87

65–69 years ........................... 3.39 2.55 2.94 4.01 3.25 3.60

70–74 years ........................... 3.20 3.81 3.55 4.39 5.12 4.81

75–79 years ........................... 7.15 5.26 6.02 9.40 8.62 8.93

80–84 years ........................... 8.17 13.21 11.30 12.62 20.09 17.32

85 years and over ........................ 16.03 20.04 18.75 26.29 38.42 34.87

5 years and over ........................ 1.24 1.56 1.40 1.57 2.42 2.01

SOURCE: National Center for Health Statistics. National Health Interview Survey (community), National Nursing Home Survey (nursing home residents), and Division of Vital Statistics.

60 The Impact of Incomplete Data on Healthy Life Expectancy Estimates
Table 5.5. Percentage of population needing help with at least one activity of daily living or instrumental activity of daily

living, by age, sex, and place of residence: United States, 1995

Community residents only Community and nursing home residents

Age Male Female Total Male Female Total

5–9 years ............................. 0.66 0.35 0.51 0.67 0.35 0.51

10–14 years ........................... 0.57 0.24 0.41 0.57 0.24 0.41

15–19 years ........................... 0.50 0.34 0.42 0.51 0.34 0.42

20–24 years ........................... 0.77 1.19 0.98 0.77 1.20 0.99

25–29 years ........................... 1.03 1.19 1.11 1.05 1.20 1.13

30–34 years ........................... 1.11 1.76 1.44 1.14 1.77 1.46

35–39 years ........................... 1.88 2.40 2.14 1.92 2.41 2.17

40–44 years ........................... 2.00 3.07 2.54 2.06 3.10 2.59

45–49 years ........................... 2.18 3.38 2.79 2.23 3.46 2.86

50–54 years ........................... 3.85 5.23 4.56 3.97 5.35 4.68

55–59 years ........................... 4.29 6.63 5.50 4.49 6.81 5.69

60–64 years ........................... 6.09 6.76 6.45 6.53 7.18 6.88

65–69 years ........................... 7.22 9.03 8.20 7.86 9.70 8.86

70–74 years ........................... 8.45 11.08 9.95 9.62 12.31 11.16

75–79 years ........................... 13.66 17.29 15.83 15.82 20.28 18.49

80–84 years ........................... 17.96 29.14 24.91 22.00 34.83 30.08

85 years and over ........................ 34.22 45.37 41.80 42.38 58.03 53.46

5 years and over ........................ 2.85 4.59 3.75 3.19 5.44 4.35

SOURCE: National Center for Health Statistics. National Health Interview Survey (community), National Nursing Home Survey (nursing home residents), and Division of Vital Statistics.

Table 5.6. Expected years of life and healthy years of female community dwellers and nursing home residents at selected

ages: United States, 1995

Healthy years1 Healthy years2

Life Community and Difference Difference Community and Difference Difference

Age expectancy3 Community nursing home in years4 in percent5 Community nursing home in years4 in percent5

65 years ............. 18.8 17.3 16.4 †0.900 5.2 15.0 14.3 †0.700 4.7

70 years ............. 15.1 13.7 12.7 †

0.994 7.3 11.5 10.8 †0.757 6.6

75 years ............. 11.7 10.3 9.3 †

1.000 9.7 8.3 7.5 †0.800 9.6

80 years ............. 8.7 7.2 6.1 †

1.091 15.1 5.4 4.6 †0.793 14.6

85 years and over ....... 6.0 4.8 3.7 †

1.100 22.9 3.3 2.5 †0.800 24.2

†Statistically significant (p <0.05). 1Expected years free of limitation in at least one activity of daily living.

2Expected years free of limitation in at least one activity of daily living or instrumental activity of daily living.

3Life expectancy at the indicated age for the female population, 1995.

4Calculated by subtracting ‘‘Community and nursing home’’ from ‘‘Community.’’

5Calculated by dividing ‘‘Difference in years’’ by ‘‘Community,’’ then multiplying by 100.

SOURCE: National Center for Health Statistics. National Health Interview Survey (community), National Nursing Home Survey (nursing home residents), and Division of Vital Statistics.

The Impact of Incomplete Data on Healthy Life Expectancy Estimates 61
6. Summary and Conclusion

In September 1998, NCHS sponsored a two-day 

workshop entitled ‘‘Identifying Summary Measures for 

Healthy People 2010.’’ The workshop had the following 

objectives: 

a) To provide a brief overview of the role of summary 

measures in Healthy People 2010; 

b) To identify a set of potential summary measures that 

should be considered for monitoring progress toward the 

first goal of Healthy People 2010; 

c) To examine the ability to compute the potential 

measures with existing data collection systems; and 

d) To specify a research agenda for the next decade to 

evaluate potential summary of measures. 

After considering a number of approaches, the panel 

recommended that a set of summary measures including both

mortality and various aspects of morbidity or health should

be calculated from existing or collectable data. The set of 

suggested measures that were suggested included: years of

healthy life defined as life without disability; years of life

without functioning problems; years of life without specified

diseases; years of life in very good health; and years of life

lived with good health behaviors.

It was also recommended that NCHS set a research 

agenda based on immediate, short-term, and long-term 

research needs. In the short-term, it was suggested that the 

potential need for incidence data be clarified; however, the 

measures selected for Healthy People 2010 were to be based 

on simple prevalence models using already available data. 

The purpose of this report is to present the summary of 

the work done in the initial stages of the summary measures 

development process. Though the work done so far is part of 

the overall process of building an integrated summary 

measure of health, the immediate focus was on the 

short-term needs of the research agenda. A summary 

measure of health with two components for accounting both 

fatal and non-fatal health outcomes was used to estimate 

expected years of healthy life. 

The model used in this report is based partially on life 

table techniques. The model, now commonly called 

Sullivan’s model, was first introduced in the United States in 

the late 1960s, and has been used by many countries since 

then. By 1998, for example, the number of countries that 

used Sullivan’s model to calculate health expectancy had 

reached 49 (1). The model has been useful for monitoring 

health trends; measuring health disparities between 

population subgroups; directing health care planning; 

projecting short- and long-term health status; and predicting 

health outcomes achievable through alternative health 

programs (2). For instance, over the past several years, the 

model has been used to measure specific health states: life 

expectancy without limiting or extremely long-standing 

illness (3); changes in both physical and mental states (4);

disability-free life expectancy (5–8); active life

expectancy (9); life free of institutionalization (6); life free

of severe handicap (6, 10); and dementia-free life

expectancy (11–13).

For the purpose of the current project, the model was 

used to estimate healthy years using different definitions of 

health. Most data used in the analyses are from NCHS. The 

mortality data were compiled from death certificates by the 

NCHS. Data on the health of the noninstitutionalized 

population were from NHIS, collected by NCHS. Data on 

the nursing home population were from the National Nursing 

Home Survey, also collected by NCHS. Annual midyear 

population estimates were from the U.S. Census Bureau. 

Healthy years were discussed using the prevalence of 

activity, work, and functional limitations as well as the 

prevalence of chronic arthritis, heart diseases, hypertension, 

and diabetes. Prevalence of overweight and obesity among 

adults was used to discuss HLE as a measure in the context 

of health-related behavior. Results are presented both in 

years of healthy life and as the proportion of remaining life 

spent in the healthy state. 

The report focused on the interpretation of the estimated 

HLEs and the variation of the results by measure. Healthy 

life expectancies estimated using different definitions of 

health were presented in chapter 3. Most of the measures 

used show that, compared to men of the same age, women 

would expect more years of healthy life (table 6.1). Yet, 

when HLE is expressed as a proportion of life expectancy, 

women would expect a smaller proportion of their lives to 

be healthy compared to men of the same age. These 

measures also show that the gender difference in the 

proportion of life expectancy that is considered healthy 

persists even at older ages. This is true both for white as 

well as black adults (table 6.2). 

Annual data between 1985 and 1995 were used to 

investigate trends in life free of activity limitation by sex 

and race, and the results of the analysis are presented in 

chapter 4. The analysis revealed that trends in years of life 

free of activity limitation varied by age, sex, and race. 

Between 1985 and 1995, there have been net gains in life 

expectancy for each of the four population subgroups. With 

regard to years of life free of activity limitation, trends 

varied by race and sex. White males, and females of both 

races gained in activity limitation-free years between 1985 

and 1995. The number of activity limitation-free years 

gained by white males were more than those gained by 

either white females or black females. The number of 

activity limitation-free years gained by white females were 

almost the same as years gained by black females. Except at 

age 65, between 1985 and 1995, black males lost all of their 

62 Summary and Conclusion
gained life expectancy to activity limitation. At age 65, gains 

in life free of activity limitation were observed for all of the 

four population subgroups. 

A comparison of gains in life expectancy and life free of 

activity limitation at birth, age 20, and age 65 revealed 

different patterns by age and ethnic group. At age 65, not 

only was there a gain in life expectancy for each group, but 

the gain was totally free of activity limitation. That is, there 

was an overall gain in quality life years. For younger age 

groups, in general, there was a gain in years free of activity 

limitation; however, the gain in life expectancy was greater 

than that in quality life years. However, for the black men, 

though there was a gain in life expectancy, there was a gain 

in years with activity limitation rather than years without 

activity limitation. Hence, not only were the years gained 

lost to activity limitation, but there was an increase in 

activity limitation in general. 

The omission of data on the health status or mortality of 

a particular population subgroup will introduce a bias into 

estimates, especially when the health (or mortality) 

experience of the subgroup is different from the population 

at large. Such biases, however, can be reduced by 

incorporating data on the population subgroup from a 

different survey. The impact of bias introduced due to the 

incompleteness of data in the estimation of years of healthy 

life was tested using data from the NHIS and the NNHS 

data for the year 1995, and the results are presented in 

chapter 5. 

Years free of functional limitation were estimated 

separately with and without the NNHS data. Not including 

the nursing home population in the morbidity component of 

summary measures of health would result in the 

overestimation of expected years of healthy life. The 

overestimation of healthy life increases with age, especially 

at the older ages. When measuring functional disability in 

terms of needing help in at least one ADL, without including 

health data on the nursing home population, healthy life at 

age 65 is overestimated by nine-tenths of a year or 

5.2 percent (from 16.4 years to 17.3 years). At age 80, HLE 

is overestimated by 1.1 year or 15.1 percent, that is, from 

6.1 to 7.2 years. 

The report also compared results by measure for the total 

population and for population subgroups by holding constant 

major determinants of population subgroups such as age, 

sex, and race constant. The comparisons of results by 

measure show that estimates vary by measure, and this was 

to be expected because the measures assess different 

dimensions of health. Healthy life expectancies estimated 

using 11 different definitions of health were compared. The 

comparisons of the results by measure were made at 30 and 

65 years of age for the total population, by sex. Results were 

also compared by measure, age, and sex, holding race 

constant; and by measure, age, and race (for white and black 

persons), holding sex constant. 

Comparisons of results by measure at ages 30 and 65 

showed that estimates varied by measure for the total 

population as well as for males and females. On average, a 

person at both 30 and 65 years of age would expect to have 

longer life of healthy years when health is defined based on 

years to be spent without needing help in ADL or IADL, 

and the same person would expect to have the shortest HLE 

when health is defined as self-assessed ‘‘excellent’’ health. 

Expected years of healthy life defined based on the 

prevalence of chronic diseases fell between the maximum 

and minimum estimates. Variations between results by 

measure were smaller at the younger ages compared to the 

older ages, and they were larger between the races (white 

versus black) than between the sexes (figures 3.21 and 3.22). 

The variations of the results by measure have several 

implications. These variations support the fact that numerous 

health measures should be used to estimate various 

dimensions of health. At the same time, since the variation 

in results may be partly due to factors exogenous to the 

various definitions of health, the observed variations by 

measure should be interpreted prudently. As noted in chapter 

5, for example, excluding the institutional population health 

data in the estimation of HLEs for the total population 

affects estimates at the older ages, and the exclusion of 

health data on the correction facilities population is expected 

to affect the HLE estimates of black adult males compared 

to any other population subgroup. 

Results of the numerous analyses also suggest that HLE 

calculated using data that are readily available could 

sufficiently satisfy the short-term research needs of 

estimating trends and group disparities in health. The 

Sullivan method uses data on prevalence of health states. 

When incidence rates are stable over time, estimates derived 

based on this model are the same as estimates based on a 

multi-state life table model (14). It has also been noted that 

the Sullivan method tends to under- or overestimate health 

expectancy if incidence rates between states of health change 

rapidly, even when prevalence rates between two periods 

remain the same (15). 

Finally, the model used in this study is simple, the 

estimates are easy to understand and interpret, and most of 

the data needed are available. The model can be used to 

measure trends in population health as well as health 

disparities between population subgroups. Since HLEs can 

be calculated based on a variety of health definitions, it 

could serve as a practical and useful tool for monitoring 

specific objectives of Healthy People 2010 that are being 

tracked based on a single health attribute. The model can 

also be used as an integral part of a set of models that can 

measure current health status based prevalence rates and 

models that use longitudinal data to measure the dynamics 

of health states, including the transition from any health state 

to death. While the utility of the measures presented in this 

report needs to be optimized, the need for more health 

measures cannot be overemphasized. Also, the need for 

multiple measures and the need to measure in terms of years 

as well as percentage of remaining years in a given health 

state adds to the complexity and provides evidence for the 

conclusion that there are no simple measures of health. 

Summary and Conclusion 63
References

1.Robine JM, Romie I. Healthy active aging: Health 

expectancies at age 65 in different parts of the world. REVES 

paper No. 318. Montpellier, France. 1998. 

2.Bone MR, et al. Health expectancy and its uses. London: 

HSMO. 1995. 

3.Valkonen T, et al. Disability-free life expectancy by level of 

education in Finland. In Mathers CD, et al., (eds.). Advances 

in health expectancies. Canberra: Australian Institute of Health 

and Welfare, AGPS. 1994. 

4.Robine, Ritchie. Healthy life expectancy: Evaluation of a new 

global indicator of change in population health. BMJ 302: 

457–60. 1991. 

5.Bebbington, AC. The expectation of life without disability in 

England and Wales: 1976–1988. Popul Trends 66:26–9. 1991. 

6.Mathers, CD. Trends in health expectancies in Australia 

1981–1993. J Aust Popul Assoc 13:1–15. 1996. 

7.Crimmins EM, Saito Y, Ingegneri D. Changes in life 

expectancy and disability-free life expectancy in the United 

States. Popul Dev Review 15:235–67. 1989. 

8.Crimmins EM, Saito Y, Ingegneri D. Trends in disability-free 

life expectancy in the United States, 1970–90. Popul Dev 

Review 23:555–572. 1997. 

9.Manton KG, Stallard E. Cross sectional estimates of life 

expectancy for the U.S. elderly and oldest-old populations. 

J Gerontol 46:S170–S182. 1991. 

10.Mathers, CD. Health expectancies in Australia, 1981 and 

1988. Canberra: Australian Institute of Public Health. 1991. 

11. Ritchie K, Mathers C, Jorm A. Dementia-free life expectancy 

in Australia. Aust J Public Health 18:149–52. (1994a). 

12.Ritchie K, et al. Dementia-free life expectancy in France. Am 

J Public Health 82(2) 232–6. (1994b). 

13.Perenboom RJM, et al. Dementia-free life expectancy in the 

Netherlands. Soc Sci Med 43:1703–7. 1996. 

14.Mathers, CD. Development in the use of health expectancy 

indicators for monitoring and comparing the health of 

populations. Report prepared for OECD, background paper 

No. 1. 1997. 

15.Jagger C. Health expectancy calculation by the Sullivan 

method: A practical guide. Euro-REVES. 1999. 

64 Summary and Conclusion
Table 6.1. Absolute and relative differences in male and female healthy life expectancy at 30 and 65 years of age:

United States, 1995

Women compared to men

Healthy life Proportion of

Age expectancy life expectancy

At 30 years of age

In good or better health ..................................... More Smaller

In excellent health ......................................... Less Smaller

Without major activity limitation ................................. More Larger

Without any activity limitation .................................. More Smaller

Without functional limitation (ADL)1 .............................. More Smaller

Without functional limitation (ADL or IADL)2 ......................... More Smaller

Without chronic arthritis ..................................... Less Smaller

Without chronic heart disease ................................. More Larger

Without hypertension ....................................... More Smaller

Without diabetes .......................................... More Similar

Without physical illness ..................................... More Smaller

Without mental illness ...................................... More Smaller

With BMI less than 253 ...................................... More Larger

With BMI less than 303 ...................................... More Smaller

Without a doctor visit ....................................... Less Smaller

Without short hospital stay ................................... More Similar

At 65 years of age

In good or better health ..................................... More Larger

In excellent health ......................................... More Similar

Without major activity limitation ................................. More Larger

Without any activity limitation .................................. More Smaller

Without functional limitation (ADL)1 .............................. More Smaller

Without functional limitation (ADL or IADL)2 ......................... More Smaller

Without chronic arthritis ..................................... Less Smaller

Without chronic heart disease ................................. More Larger

Without hypertension ....................................... Same Smaller

Without diabetes .......................................... More Larger

Without physical illness ..................................... More Smaller

Without mental illness ...................................... More Smaller

With BMI less than 253 ...................................... More Larger

With BMI less than 303 ...................................... More Smaller

Without a doctor visit ....................................... Same Smaller

Without short hospital stay ................................... More Larger

1ADL refers to activities of daily living. 2IADL refers to instrumental activities of daily living.

3BMI refers to body mass index.

Summary and Conclusion 65
Table 6.2. Absolute and relative differences in male and female healthy life expectancy for the white and black

populations at 30 and 65 years of age: United States, 1995

Women compared to men

Healthy life Proportion of

Age, race, and health status expectancy life expectancy

At 30 years of age

White:

In good or better health .................................... More Smaller

Without any activity limitation ................................ More Smaller

Without functional limitation (ADL or IADL)1 ....................... More Smaller

With BMI less than 302 .................................... More Smaller

Black:

In good or better health .................................... More Smaller

Without any activity limitation ................................ More Smaller

Without functional limitation (ADL or IADL)1 ....................... More Smaller

With BMI less than 302 .................................... Similar Smaller

At 65 years of age

White:

In good or better health .................................... More Larger

Without any activity limitation ................................ More Smaller

Without functional limitation (ADL or IADL)1 ....................... More Smaller

With BMI less than 302 .................................... More Smaller

Black:

In good or better health .................................... More Smaller

Without any activity limitation ................................ Similar Smaller

Without functional limitation (ADL or IADL)1 ....................... More Smaller

With BMI less than 302 .................................... Similar Smaller

1ADL refers to activities of daily living; IADL refers to instrumental activities of daily living. 2BMI refers to body mass index.

66 Summary and Conclusion
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