About the Annual report

America’s Health Rankings® Annual Report is the longest-running annual assessment of the nation’s health on a state-by-state basis. For the past 26 years, America’s Health Rankings® Annual Report has analyzed a comprehensive set of behaviors, community and environmental conditions, policies, and clinical care data to provide a holistic view of the health of the nation.

America’s Health Rankings® Annual Report is the result of a partnership between United Health Foundation and the American Public Health Association.

1. Introduction & Purpose

Introduction

Health is a result of our individual genetic predisposition to disease, behaviors, community and environment, policies, and clinical care. Each of us—individually, as a community, and as a society—strives to optimize these health determinants so that all can have a long, disease-free, and robust life regardless of race, ethnicity, gender, or socioeconomic status.

This report looks at the 4 groups of health determinants that can be affected:

1.      Behaviors include everyday activities that affect personal health. Behaviors include habits and practices we develop as individuals and families that influence our personal health and the use of health resources. Individuals can modify these behaviors with support of community, policy, and clinical interventions.

2.      Community and Environment influence quality of life and life expectancy. Healthy and safe communities include those with clean water and air, affordable and secure housing, sustainable and economically vital neighborhoods, and support structures such as violence-free places to be physically active.[1]

3.      Policy influences availability of resources to encourage and maintain health. Policy also influences the extent that public and health programs penetrate the general population. Policies can have a wide reach throughout a state, and they promote healthy living and judicious consumption of health care resources.

4.      Clinical care reflects the access, quality, appropriateness, and cost of care we receive at doctors’ offices, clinics, and hospitals.

Health determinants are intertwined and must work together to be optimally effective. For example, an initiative that addresses tobacco cessation requires individual effort and community support in the form of policies promoting non-smoking and effective counseling and care at clinics. Similarly, reducing the risk of low birthweight babies requires individual effort, education, access to and availability of prenatal care, and high quality health care services. Addressing obesity requires individual actions complemented by food producers and distributors, restaurants, grocery and convenience stores, exercise facilities, parks, urban and transportation design, building design, educational institutions, community organizations, social groups, health care delivery, and insurance.

The America’s Health Rankings® Annual Report combines individual measures of each of these determinants with the resultant health outcomes to produce a comprehensive view of the overall health of each state.

The America’s Health Rankings® Annual Report employs a unique methodology developed and reviewed annually by a panel of leading public health scholars. This methodology balances the contributions of various factors to state health such as smoking, obesity, physical inactivity, binge drinking, high school graduation rates, children in poverty, access to care, and incidence of preventable disease. The report is based on data from the US Department of Health and Human ServicesCommerceEducationJustice, and Labor; US Environmental Protection AgencyUS Census Bureau; the American Medical Association; the American Dental Association; the Dartmouth Atlas of Health Care; the Trust for America’s Health; and the World Health Organization.

The 2015 America’s Health Rankings® Annual Report is considered a benchmark of the relative health of states due to its longevity and its sound model. Numerous states incorporate this report into their annual review of programs, and several organizations use this study as a reference point when assigning goals for health-improvement programs.

 

PURPOSE

The ultimate purpose of America’s Health Rankings® Annual Report is to stimulate action by individuals, elected officials, health care professionals, public health professionals, employers, educators, and communities to improve the health of the US population. The report promotes public conversation concerning health in our states and provides information to facilitate citizen, community, and group participation. Participation is encouraged regarding behaviors, community and environment, clinical care, and policy. Each person as an individual, employee, employer, educator, voter, community volunteer, health care professional, public health professional, or elected official can contribute to the advancement of state health. Proven, effective, and innovative actions can improve the health of people in every state no matter where it is ranked.

 

[1] National Prevention Council. National Prevention Strategy Healthy and safe community environments. http://www.surgeongeneral.gov/initiatives/prevention/strategy/healthy-and-safe-community-environments.html. Accessed December 2, 2014.

 

2. Acknowledgment

The United Health Foundation, along with our partner the American Public Health Association, is pleased to present the 26th edition of America’s Health Rankings® Annual Report: A Call to Action for Individuals and Their Communities. First published in 1990, the Annual Report provides the longest-running state-by-state analysis of factors affecting the health of individuals and communities across America. It delivers an in-depth, trusted view into the status of America’s health that has been used by state and local public health leaders across the country to inform state health priorities and help transform health systems.

The Annual Report would not be possible without the collaboration, guidance, and expertise of our Scientific Advisory Committee. The committee is comprised of leading public health scholars and led by Anna Schenck, PhD, MSPH, Director of the Public Health Leadership Program and North Carolina Institute for Public Health at the University of North Carolina Gillings School of Global Public Health. The committee regularly reviews, discusses, and modifies the methodological framework used to ensure that the Annual Report meets the most rigorous statistical standards and accurately reflects the state of our nation’s health.

The 2015 America’s Health Rankings® Annual Report shows improvements in preventable hospitalizations, decreases in cigarette smoking, and increases in immunizations among children and adolescents—all marking progress in some of our public health challenges. However, these gains are set against a backdrop where different and complex health challenges are compromising our nation’s health. The rates of drug deaths, diabetes, obesity, and children living in poverty are currently on the rise.

I am pleased to announce that in 2016, the United Health Foundation will build upon the successes of America’s Health Rankings® by introducing a robust new suite of reports that use data and insights from the Annual Report as a foundation. We will release reports examining the health of mothers and infants as well as our nation’s veteran population; these will complement the existing Annual Report and America’s Health Rankings® Senior Report. We will also issue new “spotlight” reports in 2016 that examine important markers of our nation’s public health, such as substance abuse, prevention, healthy lifestyles, and mental health. Taken together, this new set of America’s Health Rankings® reports will create deeper insights that can inform stakeholders as they work to improve the health of our nation.

As America’s Health Rankings® expands its focus, we at the United Health Foundation invite public health officials, thought leaders, and stakeholders from across society, business, health, and government to share their perspectives on the reports through social media such as Facebook and Twitter @AHR_Rankings and through our website. We also encourage you to share ideas or programs that have made a difference in your community by emailing AHR@uhg.com.

On behalf of my colleagues, we thank Reed Tuckson, MD, Rhonda Randall, DO, and Russ Bennett for their ongoing commitment and collaboration in the dissemination of the America’s Health Rankings® Annual Report.

The United Health Foundation also acknowledges the following agencies and organizations for providing data that make this Annual Report possible. Our thanks to the US Department of Health and Human Services (CDC), US Department of Commerce (CB, BEA), US Department of Education (NCES), US Department of Justice (FBI), US Department of Labor (BLS), US Environmental Protection Agency, American Dental AssociationAmerican Medical Association, Dartmouth Atlas of Health Care, Trust for America's Health, World Health Organization, and the many others who provided valuable information about our nation’s health.

Finally, at the United Health Foundation, we are especially grateful for America’s health care workers, policy makers, and public health professionals who work to improve our nation’s health. Thanks to their tireless efforts in communities across the country, we are better prepared to address the public health changes of today and tomorrow. They deserve our deepest appreciation.

 

Chris Stidman

President, United Health Foundation

 

3. Scientific Advisory Committee

The Scientific Advisory Committee, led by Anna Schenck, PhD, MSPH, at the University of North Carolina Gillings School of Global Public Health, meets annually to review America’s Health Rankings® Annual Report. The committee assesses the report for potential improvements that maintain the value of the comparative, longitudinal information; uses new or improved health measures as they become available; and incorporates new methods as feasible. The committee reflects the evolving role and science of public health, and it emphasizes the importance of America’s Health Rankings® Annual Report as a vehicle to promote and improve the general discussion of public health. Finally, the committee encourages balance among public health efforts to benefit the entire community.

The Scientific Advisory Committee represents a variety of stakeholders including representatives from local health departments, members of the Association of State and Territorial Health Officials and the American Public Health Association, as well as experts from many academic disciplines. Scientific Advisory Committee members include:

 

Anna Schenck, PhD, MSPH, Chair

Director, Public Health Leadership Program

UNC Gillings School of Global Public Health

University of North Carolina at Chapel Hill

 

Dennis P Andrulis, PhD, MPH

Senior Research Scientist

Texas Health Institute

 

Jamie Bartram, PhD

Director

The Water Institute at UNC

UNC Gillings School of Global Public Health

University of North Carolina at Chapel Hill


Bridget Booske Catlin, PhD, MHSA

Senior Scientist and MATCH Group Director

University of Wisconsin Population Health Institute

Director, County Health Rankings & Roadmaps

 

Andrew Coburn, PhD

Professor and Associate Dean

Muskie School of Public Service

University of Southern Maine

Leah Devlin, DDS, MPH

Professor of the Practice, Health Policy and Management

UNC Gillings School of Global Public Health

University of North Carolina at Chapel Hill


Marisa Domino, PhD
Professor, Health Policy and Management
UNC Gillings School of Global Public Health

University of North Carolina at Chapel Hill

 

John Dreyzehner, MD, MPH, FACOEM

Commissioner of Health

Tennessee Department of Health

 

Tom Eckstein, MBA

Principal

Arundel Metrics, Inc

 

Paul Campbell Erwin, MD, DrPH

Professor and Department Head

Department of Public Health

University of Tennessee

 

Jonathan E Fielding, MD, MPH, MBA, MA

Professor of Health Services and Pediatrics

UCLA School of Public Health

Former Director of Public Health and Health Officer, Los Angeles County Department of Public Health

 

Marthe Gold, MD

Logan Professor and Chair

Department of Community Health

CUNY Medical School

 

Glen P Mays, PhD, MPH

F Douglas Scutchfield Endowed Professor

Health Services and Systems Research

University of Kentucky College of Public Health

 

Matthew T McKenna, MD, MPH

Medical Director

Fulton County Department of Health and Wellness

 

Anne-Marie Meyer, PhD
Faculty Director

Integrated Cancer Information and Surveillance System
UNC Lineberger Comprehensive Cancer Center
 

Sarah Milder, MPH

Principal and Epidemiologist

Arundel Metrics, Inc

 

Rhonda Randall, DO

Chief Medical Officer

UnitedHealthcare Retiree Solutions

 

Patrick Remington, MD, MPH

Associate Dean for Public Health

University of Wisconsin School of Medicine and Public Health

 

Thomas C Ricketts, PhD, MPH

Professor of Health Policy and Administration and Social Medicine

UNC Gillings School of Global Public Health

University of North Carolina at Chapel Hill

 

Mary C Selecky

Washington State Secretary of Health (retired)

 

Katie Sellers, DrPH

Chief Program Officer, Science and Strategy

Association of State and Territorial Health Officials

 

Leiyu Shi, PhD

Professor

Department of Health Policy and Management

Co-Director, Primary Care Policy Center for the Underserved

Johns Hopkins University School of Public Health

 

Steven Teutsch, MD, MPH

Chief Science Officer

Los Angeles County Department of Public Health

Director and Health Officer

4. Methodology

For each measure, the raw data are obtained from secondary sources and presented as “value.” The score for each state is based on the following formula:

                                                State Value – National Mean

                        Score =         —————————-----------------------------------------

                                                Standard Deviation of All State Values

This “z score” indicates the number of standard deviations a state is above or below the national value. A 0.00 indicates a state has the same value as the nation. States with higher values than the national value have a positive score; states below the national value have a negative score. To prevent an extreme score from exerting excessive influence, the maximum score for a measure is capped at +/- 2.00. If a US value is not available for a measure, the mean of all state values is used with the exception of measures from the Behavioral Risk Factor Surveillance System (BRFSS). For BRFSS measures, the median of the state values is used for the US value to conform to the Centers for Disease Control and Prevention tradition. Overall score is calculated by adding the scores of each measure multiplied by its assigned weight (the percentage of total overall ranking).

The overall ranking is the ordering of each state according to the overall score. The ranking of individual measures is the ordering of each state according to the measure’s value, with the exception of Infectious Disease and Immunizations-Adolescents, which are ranked according to score. Ties in values are assigned equal ranks. Not all changes in rank are statistically significant. See more details at www.americashealthrankings.org/about/annual?tabname=methodology.

5. Measure Selection

Four primary considerations drive the design of America’s Health Rankings® Annual Report and the selection of individual measures:

1. The overall rankings have to represent a broad range of issues that affect a population’s health.

2. Individual measures need to use common health-measurement criteria.

3. Data have to be available at a state level.

4. Data have to be current and updated periodically.

While not perfect, the measures selected are believed to be the best indicators of the various aspects of healthiness and are consistent with past reports. For the America’s Health Rankings® Annual Report to continue to meet its objectives, it must evolve and incorporate new information as it becomes available.

The Scientific Advisory Committee guides the evolution of the Annual Report, helping the report balance the need for change with the desire for longitudinal comparability. Over the last few years, change is being driven by: 1) acknowledgment 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 that are becoming available on a comparative basis; and 3) measurement of additional determinants of health that are being initiated and/or improved. The committee also emphasizes that the real impact on health will be made by addressing the determinants, and making improvements on these determinants will affect the long-term health of the population. The determinants are the predictors of our future health.

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 that the overall ranking may disguise 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.

 

6. Weighting of Measures

Three criteria are considered when assigning weights to measures:

1.         What effect does a measure have on overall health?

2.         Is the effect measured solely by this measure, or is it included in other measures?

3.         How reliable are the data supporting a measure?

The final weights, presented in the table below, are based on input from experts in 1990 and 1991 as well as from the Scientific Advisory Committee and its continuing methodological review.

The weights of the measures total 100%. Determinants account for 75% of the overall score, and outcomes account for 25%--a shift from the 50/50 balance in the original 1990 index. This reflects the importance and growing availability of Determinants data.

The column labeled “% of Total” indicates the weight of each measure in determining the overall score. For example, prevalence of smoking is 7.5% of America’s Health Rankings® Annual Report.

The column labeled “Effect on Score” presents how each measure positively or negatively relates to the overall ranking. For example, a high prevalence of smoking has a negative effect on score and will lower the ranking of a state. An increase in the percentage of high school graduates has a positive effect on score and will increase the overall state ranking.

Name of Measure

% of Total

Effect on Score

Determinants
75.0
 
Behaviors
25.0
 
  Smoking
7.5
Negative
  Excessive Drinking
2.5
Negative
  Drug Deaths
2.5
Negative
  Obesity
5.0
Negative
  Physical Inactivity
2.5
Negative
  High School Graduation
5.0
Positive
Community & Environment
22.5
 
  Violent Crime
5.0
Negative
  Occupational Fatalities
2.5
Negative
  Children in Poverty
5.0
Negative
  Infectious Disease
5.0
Negative
  Air Pollution
5.0
Negative
Policies
12.5
 
  Lack of Health Insurance
5.0
Negative
  Public Health Funding
2.5
Positive
  Immunizations--Children
2.5
Positive
  Immunizations--Adolescents
2.5
Positive
Clinical Care
15.0
 
  Low Birthweight
3.75
Negative
  Primary Care Physicians
3.75
Positive
  Dentists
3.75
Positive
  Preventable Hospitalizations
3.75
Negative
Outcomes
25.0
 
  Diabetes
3.125
Negative
  Poor Mental Health Days
3.125
Negative
  Poor Physical Health Days
3.125
Negative
  Disparity in Health Status
3.125
Negative
  Infant Mortality
3.125
Negative
  Cardiovascular Deaths
3.125
Negative
  Cancer Deaths
3.125
Negative
  Premature Death
3.125
Negative
   
 
 
Overall Health Rankings
100.0
---

 

7. Summary of all Measures

The tables on the tabs below provide a short definition of each measure used in the America’s Health Rankings® Annual Report. Also included are the data source for the measure and the data year(s) used in the 2015 edition.

Determinants Outcomes Supplemental

Determinants

Determinants are broken into 4 sub-groups; Behaviors, Community & Environment, Policy, and Clinical Care.

Determinant

Description

Source

Data Year(s)

Behaviors

 

 

Smoking

Percentage of adults who are self-reported smokers (smoked at least
100 cigarettes in their lifetime and currently smoke)

Behavioral Risk Factor Surveillance System

2014

Excessive Drinking

Percentage of adults who self-report either binge drinking (consuming
more than 4 [women] or more than 5 [men] alcoholic beverages on a
single occasion in the last month) or chronic drinking (consuming 8 or
more [women] or 15 or more [men] alcoholic beverages per week

Behavioral Risk Factor Surveillance System

2014

Drug Deaths

Number of deaths due to drug injury of any intent (unintentional,
suicide, homicide, or undetermined) per 100,000 population

National VItal Statistics System

2011 to 2013

Obesity

Percentage of adults who are obese by self-report, with a body mass
index (BMI) of 30.0 or higher

Behavioral Risk Factor Surveillance System

2014

Physical Inactivity

Percentage of adults who self-report doing no physical activity or
exercise other than their regular job in the last 30 days

Behavioral Risk Factor Surveillance System

2014

High School Graduation (ACGR)

Percentage of high school students who graduate with a regular high
school diploma within 4 years of starting ninth grade

National Center for Education Statistics

2012 to 2013

Community & Environment

 

 

Violent Crime

Number of murders, rapes, robberies, and aggravated assaults per
100,000 population

Federal Bureau of Investigation

2013

Occupational Fatalities

Number of fatal occupational injuries in construction, manufacturing,
trade, transportation, utilities, professional services, and business services per 100,000 workers

Census of Fatal Occupational Injuries, Bureau of Economic Analysis

 

2012 to 2014P

Children in Poverty

Percentage of persons younger than 18 years who live in households at or below the poverty threshold

Curent Population Survey, 2015 Annual Social and Economic Supplement

2014

Infectious Disease

Combined average z score using the incidence of Chlamydia, pertussis,
and Salmonella per 100,000 population

Summary of Notifiable Diseases MMWR, NCHHSTP Atlas

2013

Air Pollution

Average exposure of the general public to particulate matter of 2.5
microns or less in size (PM2.5)

Environmental Pollution Agency 

2012 to 2014

Policy

 

 

Lack of Health Insurance

Percentage of the population that does not have health insurance privately, through their employer, or through the government

American Community Survey

2013 to 2014

Public Health Funding

 

State dollars dedicated to public health and federal funding directed to states by the Centers for Disease Control and Prevention and the Health Resources and Services Administration

Trust for America's Health

2013 to 2014

Immunization-Children

Percentage of children aged 19 to 35 months receiving the recommended doses of DTaP, polio, MMR, Hib, hepatitis B, varicella, and PCV vaccines

National Immunization Survey

2013

Immunizations-Adolescents

Percentage of adolescents aged 13 to 17 years who have received 1 dose
of Tdap since the age of 10 years, 1 dose of meningococcal conjugate
vaccine, and 3 doses of HPV (females and males)

National Immunization Survey

2014

Clinical Care

 

 

Low Birthweight

Percentage of infants weighing less than 2,500 grams (5 pounds, 8
ounces) at birth

National Vital Statistics System

2013

Primary Care Physicians

Number of primary care physicians (including general practice, family
practice, OB-GYN, pediatrics, and internal medicine) per 100,000
population

American Medical Association

2013

Dentists

Number of practicing dentists per 100,000 population

American Dental Association

2013

Preventable Hospitalizations

Number of discharges for ambulatory care-sensitive conditions per 1,000
Medicare beneficiaries

The Dartmouth Atlas of Health Care

2013

Outcomes
 

Outcome

Description

           

 

Diabetes

Percentage of adults who responded yes to the question: “Have you ever been told by a doctor that you have diabetes?” (excludes pre-diabetes and gestational diabetes)

Behavioral Risk Factor Surveillance System

2014

Poor Mental Health Days

Number of days in the past 30 days that adults self-reported their mental health was not good

Behavioral Risk Factor Surveillance System

2014

Poor Physical Health Days

Number of days in the past 30 days that adults self-reported their physical health was not good

Behavioral Risk Factor Surveillance System

2014

Disparity in Health Status

Difference in the percentage of adults with vs. without a high school degree who self-reported that their health was very good or excellent

Behavioral Risk Factor Surveillance System

2014

Infant Mortality

Number of infant deaths (before age 1) per 1,000 live births

National Vital Statistics System

2012 to 2013

Cardiovascular Deaths

Number of deaths due to all cardiovascular diseases including heart disease and strokes per 100,000 population

National Vital Statistics System

2011 to 2013

Cancer Deaths

Number of deaths due to all causes of cancer per 100,000 population

National Vital Statistics System

2011 to 2013

Premature Death

Number of years of potential life lost before age 75 per 100,000 population

National Vital Statistics System

2013

The Supplemental measures are divided into the following categories; Behaviors, Chronic Disease, Clinlcal Care, Economic Environment, and Outcomes.

Determinants

Description

Source

Data Year(s)

Behaviors

Binge Drinking 

Percentage of adults who self-report consuming 4 or more (women)
or 5 or more (men) alcoholic beverages on at least 1 occasion in the last month

Behavioral Risk Factor Surveillance System 

2014

Chronic Drinking 

Percentage of adults who self-report consuming 8 or more alcoholic
beverages per week (women) or 15 or more alcoholic beverages per
week (men)

Behavioral Risk Factor Surveillance System 

2014

Cholesterol Check*

Percentage of adults who self-report having their blood cholesterol checked within the last 5 years

Behavioral Risk Factor Surveillance System 

2014

Dental Visit, Annual 

Percentage of adults who self-report visiting the dentist or dental clinic within the past year for any reason

Behavioral Risk Factor Surveillance System 

2014

Fruits*

Self-reported number of fruits consumed by adults in an average day

Behavioral Risk Factor Surveillance System 

2014

Vegetables*

Self-reported number of vegetables consumed by adults in an average day

Behavioral Risk Factor Surveillance System 

2014

Insufficient Sleep 

Percentage of adults who self-report sleeping fewer than 7 hours in a 24-hour period, on average

Behavioral Risk Factor Surveillance System 

2014

Teen Birth Rate 

Number of births per 1,000 females aged 15 to 19 years

National Vital Statistics System 

2013

Youth Smoking*

Percentage of high school students who self-report smoking cigarettes on at least 1 day during the past 30 days

Youth Behavioral Risk Surveillance System 

2013

Youth Obesity*

Percentage of high school students who were greater than or equal to the 95th percentile for body mass index, based on sex and age-specific reference data from the 2000 CDC growth charts

Youth Behavioral Risk Surveillance System 

2013

Chronic Disease  

Heart Disease 

Percentage of adults who self-report being told by a health professional that they have angina or coronary heart disease

Behavioral Risk Factor Surveillance System 

2014

High Cholesterol*

Percentage of adults who self-report having their cholesterol checked and being told it was high

Behavioral Risk Factor Surveillance System 

2014

Heart Attack 

Percentage of adults who self-report being told by a health professional that they had a heart attack (myocardial infarction)

Behavioral Risk Factor Surveillance System 

2014

Stroke 

Percentage of adults who self-report being told by a health professional that they had a stroke

Behavioral Risk Factor Surveillance System 

2014

High Blood Pressure*

Percentage of adults who self-report being told by a health professional that they have high blood pressure

Behavioral Risk Factor Surveillance System 

2014

Clinical Care 

Preterm Birth 

Percentage of babies born before 37 weeks gestation

National Vital Statistics System 

2013

Economic Environment

Personal Income 

Per capita personal income in dollars

Bureau of Economic Analysis 

2014

Median Household Income 

Dollar amount that divides the household income distribution into 2 equal groups

US Census Bureau

2014

Unemployment Rate 

Percentage of the civilian labor force that is unemployed (U-3 definition)

US Bureau of Labor Statistics 

2014

Underemployment Rate 

Percentage of the civilian labor force that is unemployed, plus all
marginally attached workers, plus the total employed part-time for
economic reasons (U-6 definition)

US Bureau of Labor Statistics 

2014

Income Disparity 

A value of 0 represents total income equality, and 1 indicates complete
income inequality (Gini coefficient)

US Census Bureau 

2014

Outcomes

High Health Status 

Percentage of adults who self-report that their health is very good or excellent

Behavioral Risk Factor Surveillance System 

2014

Suicide 

Number of deaths due to intentional self-harm per 100,000 population

National Vital Statistics System 

2013

Injury Deaths

Number of deaths due to injury per 100,000 population

National Vital Statistics System 

2011 to 2013

High School Graduation (AFGR)** 

Percentage of incoming ninth graders who graduate in 4 years from a high school with a regular diploma

National Center for Educational Statistics 

2012 to 2013

*The data appearing in this edition are the same that appeared in the 2014 edition. An update was not available at time of publication.

**The AFGR appearing in this edition was calculated from data gathered from each state Department of Education.

8. Health Disparities

Health Disparities

Measuring the distribution of health determinants and outcomes by state provides useful data on the condition of the average resident, but it often masks important differences in health within a state’s population. When health metrics are stratified by race/ethnicity, gender, age, education, place of residence, and/or economic status, significant differences can emerge that are important for states to recognize. Understanding how social determinants of health, including education, are associated with health behaviors and outcomes is essential to reducing disparities and improving population health through targeted policy development and implementation and public health practice. 

Healthy People 2020 defines health disparity as “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.”[1],[2]

Healthy People 2020’s goals are to achieve health equity, eliminate disparities, and improve the health of all groups.[1] They define health equity as the “attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities.”[1][3]

The America's Health Rankings® Annual Report provides 3 sources for determining health disparity: (1) the outcomes metric disparity in health status, (2) a data visualization tool that displays subpopulation data for select measures, and (3)10-page printable state profiles that summarize the current findings for each state and include subpopulation data for select measures. 

Disparity in Health Status

The America's Health Rankings® Annual Report contains an explicit metric for disparities. For the 2008-2012 Editions, the metric geographic disparity was used. This indicator reflected the range of age-adjusted mortality rates that existed within a state at the county level. In the 2013 Edition, the America's Health Rankings® Annual Report replaced geographic disparity with a new measure, 

. This indicator reflects the difference in self-reported high health status between adults aged 25 and older who did not graduate from high school and those with at least a high school education (graduated high school, attended college or technical school, or graduated from college or technical school). 

Current research indicates that Americans with less education live shorter lives and have poorer health. In today’s knowledge economy, higher levels of education can lead to better employment opportunities that may include health insurance, access to medical care, and financial resources to live in a healthy community. Education is also associated with healthier lifestyle and behaviors. 

Disparity Visualization

Health disparities also can be examined using the  America's Health Rankings® Annual Report disparity-visualization tool. The tool displays the estimated prevalence and the estimated number of people affected for the metrics listed below. Where available, the metrics can be viewed by education level, income level, race/ethnicity, gender, urbanicity, and age.

Behaviors

Community & Environment

Clinical Care

Outcomes

Supplemental

Smoking

Chlamydia

Low Birthweight

Diabetes

High Health Status

Excessive drinking

   

Poor Mental Health Days

Binge Drinking

Drug Deaths

   

Poor Physical Health Days

 

Obesity

 

 

Disparity in Health Status

 

Physical Inactivity

   

Infant Mortality

 

High School Graduation

   

Cardiovascular Deaths

 

 

   

Cancer Deaths

 

State Profiles

The state profiles summarize the current findings for each state and include subpopulation data for select measures. 

[1] US Department of Health and Human Services. HealthyPeople.gov Disparities. http://www.healthypeople.gov/2020/about/disparitiesAbout.aspx. Accessed October 14, 2013.

[2] US Department of Health and Human Services. The Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020. Phase I report: Recommendations for the framework and format of Healthy People 2020. Section IV. Advisory Committee findings and recommendations. http://healthypeople.gov/2020/about/advisory/Reports.aspx.  Accessed October 14, 2013.

[3] US Department of Health and Human Services, Office of Minority Health. National Partnership for Action to End Health Disparities. The National Plan for Action Draft as of February 17, 2010. Chapter 1: Introduction. http://www.minorityhealth.hhs.gov/npa/templates/browse.aspx?&lvl=2&lvlid=34. Accessed October 14, 2013.


 

9. Proposed Model Changes

Model Development

Changes Implemented in 2015

Excessive Drinking replaced Binge Drinking as a core measure, and Chronic Drinking was added as a supplemental measure. Binge Drinking and Chronic Drinking are now separate supplemental measures. Substituting Excessive Drinking for Binge Drinking allows for discussing as health risks the frequency of drinking and the amount of alcohol consumed. Also, the definition of Excessive Drinking includes both binge and chronic drinking. Using the measure Excessive Drinking aligns America’s Health Rankings® Annual Report with County Health Rankings & Roadmaps, allowing for easier comparisons between publications. See www.americashealthrankings.org/all/excessdrink.

Revised definition of High School Graduation. The National Center for Education Statistics (NCES) and all states have adopted the Adjusted Cohort Graduation Rate (ACGR) as the definitive measure of high school graduation. This measure is now preferred over the Average Freshman Graduation Rate (AFGR) for the following reasons:

1. The ACGR employs student-level data collected over a 5-year period and accounts for movement in and out of a cohort of students due to the transfer or death of students.

2. The AFGR, on the other hand, is a proxy rate indicator that is based on data available to NCES at the federal level (grade level aggregates by race/ethnicity and sex) and is a less comparable measure between states. It is still calculated because it is useful for trend analysis within a state.

3. The ACGR has been the standard for measuring graduation rates since 2011.

The ACGR is used in this edition to calculate the state ranking. As available, we will include AFGR as a supplemental measure.

The definition of Immunizations—Adolescents was revised. The National Immunization Survey doesn’t release a composite adolescent immunization coverage estimate as it does for the measure Immunizations—Children. When Immunizations—Adolescents was introduced in the 2013 America’s Health Rankings® Annual Report, a composite value was calculated by averaging the percentage of adolescents aged 13 to 17 years who received 1 dose of tetanus, diphtheria, and acellular pertussis (Tdap) vaccine since the age of 10 years; 1 dose of meningococcal conjugate vaccine (MCV4); and females who received 3 doses of human papillomavirus (HPV) vaccine. However, because HPV immunization coverage estimates are much lower than Tdap coverage estimates, this method of combination misrepresents the percentage of teens who are fully vaccinated. To address this issue, we are including coverage estimates for the 3 individual vaccines to highlight the differences in coverage by vaccine. In addition, this year data became available for male HPV immunization coverage in all states except Mississippi. We averaged the female and male z scores to create a composite HPV vaccine coverage score. In this edition of America’s Health Rankings® Annual Report, Immunization-Adolescents was calculated as the average of the z scores for Tdap, MCV4, and combined HPV (female and male). The model weight for Immunizations—Adolescents (2.5%) is equally divided among Tdap (www.americashealthrankings.org/ALL/Immunize_tdap ), MCV4 (www.americashealthrankings.org/ALL/Immunize_MCV4 ), and HPV vaccine (composite of female [www.americashealthrankings.org/ALL/immunize_hpv_female] and male [www.americashealthrankings.org/ALL/immunize_hpv_male] coverage estimates).

Added Injury Deaths as a supplemental measure. Injuries, both unintentional and intentional, are a leading cause of morbidity and mortality in the US. Unintentional injuries are the fourth-leading cause of mortality, with accidental poisonings, motor vehicle accidents, and falls the top 3 contributors. Leading causes of intentional injury fatalities include suicide by firearm, homicide by firearm, and suicide by suffocation.

Possible Changes for 2016

Each year, we consider changes in the core model to reflect the evolving understanding of population health, to improve existing data sources, to integrate new data sources, and to adjust to changing availability of information. The following areas are being explored and will be discussed at the spring Scientific Advisory Committee (SAC) meeting:

Insufficient Sleep. The importance of sleep as a public health issue is growing. The measure Insufficient Sleep will continue to be included as a supplemental measure, and its incorporation as a core measure will be reexamined at the spring SAC meeting. 

Teeth Extractions. Extraction of teeth due to disease is both an indicator of adverse current health conditions and a potential determinant of continued adverse health conditions in the future. Full extraction, limited extraction (6+ teeth), and extractions occurring before age 65 will be considered as an indicator of dental health.

Water fluoridation. Water fluoridation is considered a top-10 achievement in public health in the last century.[1] The prevalence of fluoridation in public water systems will be explored as an indicator of implementation of proven public health policy.

Sealants among Medicaid beneficiaries. The SAC will explore the prevalence of sealants among Medicaid beneficiaries as an indicator of clinical dental care in a challenged population.

Colorectal Cancer Screening. Colorectal cancer screening will be added as a supplemental measure during 2016. Incorporation of this measure into the core data set will be discussed at the SAC meeting.

Environmental pollution. The current measure Air Pollution does not fully address all avenues of pollution, especially water. This area will be explored for potential new measures to be included. Also, reconciling the differences in methodology between County Health Rankings & Roadmaps and America’s Health Rankings® Annual Report will be explored to reduce confusion among users.

All changes are explored using modeling to clarify the impact of any change. Final recommendations are made to the SAC in early spring. Approved recommendations are announced via our newsletter and social channels. If you wish to receive this information or if you have metric suggestions for America’s Health Rankings® Annual Report, contact us at www.americashealthrankings.org/home/contactus.

In addition to the proposed changes, we continue to explore indicators that reflect the following areas of health: mental health, climate change, built environment, injury, diet, exercise, health equity, and socioeconomic status indicators.

Lack of Health Insurance

America’s Health Rankings® Annual Report uses data from the US Census Bureau’s American Community Survey to calculate the percentage of the population that does not have health insurance. The data resented in this report were collected in 2013 and 2014 before full implementation of the Affordable Care Act.

 

[1] http://www.cdc.gov/about/history/tengpha.htm, accessed October 21, 2015.

 

Notes & Errors

Lack of Health Insurance

America’s Health Rankings® uses data from the US Census Bureau’s American Community Survey to calculate the percentage of the population that does not have health insurance. The data presented in this report was collected in 2013, before full implementation of the Affordable Care Act. According to results of a July 2014 Commonwealth Fund survey, an estimated 9.5 million fewer US adults were uninsured at the close of the first open enrollment period than at the beginning.

The Commonwealth Fund. http://www.commonwealthfund.org/publications/press-releases/2014/jul/after-first-aca-enrollment-period. Accessed November 20, 2014.

Map Correction

On the 2015 Edition Ranks map on page 7 of the 2015 America’s Health Rankings® Annual Report, the arrow from the callout covering New Mexico’s strengths and challenges mistakenly points to Arizona. The corrected map appears online.