摘要：Objectives. We sought to quantify the potential health impact of selected medical and nonmedical policy changes within the United States. Methods. Using data from the 1997–2000 National Health Interview Surveys (linked to mortality data through 2002) and the 1996–2002 Medical Expenditure Panel Surveys, we calculated age-specific health-related quality-of-life scores and mortality probabilities for 8 social and behavioral risk factors. We then used Markov models to estimate the quality-adjusted life years lost. Results. Ranked quality-adjusted life years lost were income less than 200% of the poverty line versus 200% or greater (464 million; 95% confidence interval [CI] = 368, 564); current-smoker versus never-smoker (329 million; 95% CI = 226, 382); body mass index 30 or higher versus 20 to less than 25 (205 million; 95% CI = 159, 269); non-Hispanic Black versus non-Hispanic White (120 million; 95% CI = 83, 163); and less than 12 years of school relative to 12 or more (74 million; 95% CI = 52, 101). Binge drinking, overweight, and health insurance have relatively less influence on population health. Conclusions. Poverty, smoking, and high-school dropouts impose the greatest burden of disease in the United States. Heart disease, cancer, and stroke are the leading causes of death in the United States and much of the world. These deaths arise in part from behavioral risk factors such as smoking, obesity, and excessive alcohol use and in part from social risk factors, such as income and education disparities. 1 – 4 Social risk factors also affect population health. 5 , 6 However, although public health policy has been directed at individual social and behavioral risks, there has been little systematic investigation of their relative contribution to US population health. Building on prior research, 7 – 10 we examined social risk in the context of health disparities resulting from an individual's membership in a socially identifiable and disadvantaged group compared with membership in a nondisadvantaged counterpart. 11 The poor health outcomes of such groups has long been linked, in part, to differential access to everyday social goods, including access to medical care, transportation, housing, and disability insurance. 4 , 12 Social risk factors affect health through a wide array of pathways including stress, discrimination, social exclusion, environmental exposures, and health behaviors. 3 , 13 – 17 We examined the potential health gains associated with selected policy goals that are at the forefront of the current national debates. These include smoking prevention, increased access to medical care, poverty reduction, and early childhood education programs targeted toward increasing high school graduation rates. To contextualize these findings, we also explored some of the priority areas from Healthy People 2010. 18 We focused on specific policies. For example, we quantified the population health benefits of poverty reduction rather than the entire income gradient 19 ; however, we did not attempt to estimate the population health impact of any 1 policy. Rather, we simply present the total burden of disease associated with each risk factor that targeted policies might address. The objective is to provide policymakers with a rough sense of how different policy priorities might influence population health.
