Four primary considerations drove the design of America`s Health RankingsTM and the selection of the individual measures:

1. The overall rankings had to represent a broad range of issues that affect a population`s health,
2. Individual measures needed to use common health measurement criteria,
3. Data had to be available at a state level, and
4. Data had to be current and updated periodically.

While not perfect, the measures selected are believed to be the best available indicators of the various aspects of healthiness at this time and are consistent with past reports.

The Scientific Advisory Committee suggested that the measures be divided into two categories - Determinants and Outcomes. For further clarity, determinants are divided into four groups: Behaviors, Community and Environment, Public and Health Policies, and Clinical Care. These four groups of measures influence the health outcomes of the population in a state, and improving these inputs will improve outcomes over time. Most measures are actually a combination of activities in all four groups. For example, the prevalence of smoking is a behavior that is strongly influenced by the community and environment in which we live, by public policy, including taxation and restrictions on smoking in public places and by the care received to treat the chemical and behavioral addictions associated with tobacco. However, for simplicity, we placed each measure in a single category.

For America`s Health RankingsTM to continue to meet its objectives, it must evolve and incorporate new information as it becomes available. The Scientific Advisory Committee provides guidance for the evolution of the rankings, balancing the need to change with the desire for longitudinal comparability. Over the last few years, change is being driven by: 1) the acknowledgement that health is more than years lived but also includes the quality of those years; 2) data about the quality and cost of health care delivery are becoming available on a comparative basis; and 3) measurement of the additional determinants of health are being initiated and/or improved. The committee also emphasizes that the real impact on health will be made by addressing the health determinants, and making improvements on these items will affect the long-term health of the population. The determinants are the predictors of our future health.

Health outcomes are traditionally measured using mortality measures including premature death, infant mortality, cancer and cardiovascular mortality. While these measures overlap significantly, they do present different views of mortality outcomes of the population. Two measures of the quality of life - poor mental health days and poor physical health days - are also included and defined as the number of days in the previous 30 days when a person indicates their activities are limited due to mental or physical health difficulties. Disparity in health outcomes is now explicitly captured in the Geographic Disparity measure.

As with all indices, the positive and negative aspects of each measure must be weighed when choosing and developing them. These aspects for consideration include:

1) the interdependence of the different measures;

2) the possibility of the overall ranking disguising the effects of individual measures;

3) an inability to adjust all data by age and race;

4) an over-reliance on mortality data; and

5) the use of indirect measures to estimate some effects on health. These concerns cannot be addressed directly by adjusting the methodology; however, assigning weights to the individual measures can mitigate their impact weights to the individual measures.

Each measure is assigned a weight that determines its percentage of the overall score. Determinants account for 75 percent of the overall ranking and outcomes account for 25 percent, a shift from the 50/50 balance in the original 1990 index. This reflects the importance and growing availability of determinant measures.