About the Annual Report

Highlights

Find out health trends in obesity, smoking, diabetes and physical inactivity, and see how states rank for overall health. Use dropdown menus to narrow or expand information.

State Rankings Obesity Smoking Diabetes Physical Inactivity

Overall State Rankings

See how states stack up on overall health. Click on states or use dropdown menu to get more information on each state.

Obesity

Explore data on one of the greatest health threats in the US, affecting more than 1 in 4 adults.

USA Obesity (1990-2015) see more
  • Percentage of the population estimated to be obese, with a body mass index (BMI) of 30.0 or higher.
  • Percentage of adults who are obese by self-report, with a body mass index (BMI) of 30.0 or higher.

Smoking

Although it is trending downward, smoking is still the leading cause of preventable death in the US.

USA Smoking (1990-2015) see more
  • Percentage of population over age 18 that smokes on a regular basis.
  • Percentage of adults who are smokers (self-report smoking at least 100 cigarettes in their lifetime and currently smoke).

Diabetes

The prevalence of diabetes is increasing in the US, but a healthy lifestyle can often prevent or delay the onset of diabetes.

USA Diabetes (1996-2015) see more
  • Percentage of adults who responded yes to the question "Have you ever been told by a doctor that you have diabetes?" Does not include pre-diabetes or diabetes during pregnancy.
  • 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).

Physical Inactivity

As a nation, we need to get up and get moving. Regular exercise is integral to a healthy lifestyle.

USA Physical Inactivity (1997-2015) see more
  • Percentage of adults who indicated that they have not participated in any physical activities outside of work during the past month.
  • Percentage of adults who self-report doing no physical activity or exercise other than their regular job in the last 30 days.

Findings

  • Overview

From the entire data set in the 2015 America’s Health Rankings® Annual Report, here are state and national highlights:

  1. Hawaii—for the fourth consecutive year—takes the title of healthiest state in 2015.
  2. North Carolina shows the biggest improvement in rank over the past year, rising to 31st from 37th.
  3. The nation shows improvement in preventable hospitalizations, decreases in physical inactivity, increases in immunizations among children and adolescents, and continued long-term improvement in less cigarette smoking, fewer cardiovascular deaths, and lower infant mortality.
  4. There are troubling increases in rates of US drug deaths, diabetes, obesity, and children in poverty. In addition, premature death rates have plateaued; many of these deaths are preventable through lifestyle modifications.

State Rankings

Healthiest

Hawaii again takes the title of healthiest state in 2015 and is followed by Vermont (2) and Massachusetts (3). Minnesota (4) and New Hampshire (5) return to the top 5.

Hawaii has consistently been in the top 6 states since the America’s Health Rankings® Annual Report launched in 1990. Hawaii scores well for having a low prevalence of obesity, low rates of preventable hospitalizations, and few poor mental health days. Immunizations among children aged 19 to 35 months—identified as a key challenge for the state last year—increased 11%, from 66.5% to 73.7% over the past year. Like all states, Hawaii also has areas needing improvement. It scores below the national average for immunizations among adolescents for the Tdap vaccine and above the national average for excessive drinking and the incidence of Salmonella

Most Improved

  • North Carolina shows the biggest improvement in rank over the past year, moving up 6 places. The state’s rise is due to an improvement in the percentage of immunizations among children and HPV immunizations among adolescent females. Also, there was a decline in physical inactivity and in the incidence of Salmonella infections.
  • Notably Improved States: Maine moves from 20th last year to 15th, Washington from 13th to 9th, Kentucky from 47th to 44th, and Delaware from 35th to 32nd.

Most Challenged

Largest Changes in Rank Since 2014 Edition (1 Year)

Rank Improved

2014 Rank

2015 Rank

Change

North Carolina

37

31

6

Maine

20

15

5

Washington

13

9

4

Delaware

35

32

3

Kentucky

47

44

3

 

 

 

 

Rank Declined

 

 

 

Oregon

12

20

8

New Mexico

33

37

4

Alabama

43

46

3

North Dakota

9

12

3

Texas

31

34

3

West Virginia

44

47

3

 

Successes

National Successes Since the 2014 Edition

 

 

National Successes—Long Term Changes

Smoking

In the last year the prevalence of smoking decreased 5% from 19.0% to 18.1% of adults. Smoking has decreased since 1990 from 29.5% to 18.1% of the adult population. However, 1 in 6 adults still smoke.

 

Physical Inactivity

In the last year the prevalence of physical inactivity decreased 11% from 25.3% to 22.6% of adults who self-report doing no exercise other than their regular job in the last 30 days.

 

Immunizations—Children and Immunizations—Adolescents

More people are getting recommended vaccines. In the past 2 years immunizations among children aged 19 to 35 months increased 5% from 68.4% to 71.6%. In 1996, the percentage was less than 60%. Similarly, in the last year HPV vaccinations among females aged 13 to 17 years increased 6% from 37.6% to 39.7%. The incidence of pertussis—a vaccine-preventable condition—decreased 41% from 15.5 to 9.1 cases per 100,000 population.

 

Preventable Hospitalizations

In the last year preventable hospitalizations decreased 8% from 62.9 to 57.6 discharges per 1,000 Medicare beneficiaries. In the past 2 years preventable hospitalizations decreased 11%, and since 2001 the decrease has been 30%.

 

Infant Mortality

Since 1990 infant mortality has decreased 41% from 10.2 to 6.0 deaths per 1,000 live births.

 

Cardiovascular Deaths

In the past 10 years cardiovascular deaths decreased 23% from 326.6 to 250.8 deaths per 100,000 population.

 

 

Challenges

National Challenges Since the 2014 Edition

 

 

National Challenges—Long Term Changes

Drug Deaths

In the last year the prevalence of drug deaths increased 4% from 13.0 to 13.5 deaths per 100,000 population.

 

Obesity

In the past 2 years obesity increased 7% from 27.6% to 29.6% of adults who are obese by self-report. In 1990 obesity was less than 12% of the adult population.

 

Children in Poverty

 

In the last year the percentage of children living in poverty increased 6% from 19.9% to 21.1% of children under age 18 years.  In 2002, 15.8% of children lived in poverty—34% less than now.

 

Diabetes

Self-reported diabetes continues to increase—now at 10.0% of the adult population. Twenty years ago it was 4.4% of the adult population.

 

Premature Death

For the third year in a row the nation has not made progress in premature death rate.

              

International Comparisons

When health in the United States is compared with health in other countries, the picture is disappointing. On nearly all indicators of mortality, survival, and life expectancy, the United States ranks at or near the bottom among high-income countries. WHO estimated the US infant mortality rate at 5.9 deaths per 1,000 live births in 2013, ranking the United States 45th among WHO nations. This ranks just below Bosnia, Serbia, and the former Yugoslavia Republic of Macedonia but slightly above Slovakia and Qatar. In 14 countries—including 7 western European countries, Japan, and Singapore—the infant mortality rate is less than half the US rate.

 

 

Another measure used to compare the health of nations is life expectancy, which is highly influenced by infant mortality rates as well as death at all ages. The United States, with a life expectancy of 79 years, ranks 34th and is tied with Costa Rica, Nauru, and Qatar. Almost all western European countries, Japan, Australia, Singapore, Canada, and New Zealand have a longer life expectancy than the United States. Nineteen countries have a life expectancy at least 3 years longer than the US life expectancy.

 

 

Global life expectancy at birth for both sexes rose 6.2 years (from 65.3 in 1990 to 71.5 in 2013). This reflects declines in death and illness caused by HIV/AIDS and malaria in the past decade and significant advances made in addressing communicable, maternal, neonatal, and nutritional disorders. Healthy life expectancy (HALE) at birth rose 5.4 years (from 56.9 in 1990 to 62.3 in 2013). HALE takes into account mortality and the impact of nonfatal conditions; it summarizes years lived with disability and years lost due to premature mortality. The HALE increase has not been as dramatic as the growth of life expectancy, and as a result, people—especially in the United States—are living more years with illness and disability. US life expectancy gains for men since 1990 was 4.4 years; for women, 2.6 years. However, men’s HALE rose 3.1 years, while women’s went up only 1.6 years. Life expectancy for US women is still better than that of US men, 81.4 years versus 76.3 years.[1]

 

In addition to US rankings for infant mortality and life expectancy being disappointingly low, US expenditure on health care, as measured by percent of gross domestic product (GDP) spent on health by private and public sectors, ranks second among 191 countries at 17.1% of GDP. Ranking first is Tuvalu at 19.7%. Only 20 countries spend more than 10% of GDP on health. All other developed countries with health expenditures more than 10% of GDP have both a lower infant mortality rate and a higher life expectancy than the United States.

 


[1] Murray CJL, Vos T, Lopez A, Barber R, Foreman K, Achoki T, et al. Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015;385:117–71.

 

Infant Mortality Life Expectancy Health Expenditures

Infant Mortality

Deaths per 1,000 live births

 

Country

Infant Mortality Rate

Rank

Iceland

1.6

1

Luxembourg

1.6

1

Finland

2.1

3

Japan

2.1

3

Andorra

2.2

5

Singapore

2.2

5

Norway

2.3

7

Slovenia

2.3

7

Sweden

2.4

9

Estonia

2.7

10

Cyprus

2.8

11

San Marino

2.8

11

Czech Republic

2.9

13

Denmark

2.9

13

Italy

3

15

Monaco

3

15

Portugal

3.1

17

Austria

3.2

18

Germany

3.2

18

Ireland

3.2

18

Israel

3.2

18

Republic of Korea

3.2

18

Netherlands

3.3

23

Australia

3.4

24

Belgium

3.5

25

France

3.5

25

Spain

3.6

27

Switzerland

3.6

27

Belarus

3.7

29

Greece

3.7

29

Croatia

3.8

31

United Kingdom of Great Britain and Northern Ireland

3.9

32

Lithuania

4

33

Poland

4.5

34

Canada

4.6

35

Montenegro

4.9

36

Cuba

5

37

Bahrain

5.2

38

Hungary

5.2

38

New Zealand

5.2

38

Malta

5.3

41

Bosnia and Herzegovina

5.7

42

Serbia

5.8

43

The former Yugoslav republic of Macedonia

5.8

43

United States of America

5.9

45

Slovakia

6

46

Qatar

7

47

United Arab Emirates

7

47

Chile

7.1

49

Malaysia

7.2

50

Latvia

7.4

51

Cook Islands

7.5

52

Antigua and Barbuda

7.7

53

Lebanon

7.8

54

Saint Kitts and Nevis

7.8

54

Kuwait

8.1

56

Sri Lanka

8.2

57

Brunei Darussalam

8.4

58

Costa Rica

8.4

58

Maldives

8.4

58

Russian Federation

8.6

61

Ukraine

8.6

61

Uruguay

9.5

63

Oman

9.8

64

Bulgaria

10.1

65

Dominica

10.2

66

Bahamas

10.4

67

Tonga

10.4

67

Romania

10.5

69

Grenada

10.7

70

China

10.9

71

Thailand

11.3

72

Georgia

11.7

73

Argentina

11.9

74

Syrian Arab Republic

11.9

74

Seychelles

12.2

76

Brazil

12.3

77

Libya

12.4

78

Mauritius

12.5

79

Mexico

12.5

79

Saint Lucia

12.7

81

Peru

12.9

82

Venezuela (Bolivarian Republic of)

12.9

82

Tunisia

13.1

84

Albania

13.3

85

Barbados

13.3

85

Republic of Moldova

13.3

85

Saudi Arabia

13.4

88

El Salvador

13.5

89

Armenia

14

90

Belize

14.3

91

Jamaica

14.3

91

Iran (Islamic Republic of)

14.4

93

Colombia

14.5

94

Kazakhstan

14.6

95

Vanuatu

14.6

95

Palau

15.1

97

Panama

15.4

98

Samoa

15.5

99

Jordan

16

100

Turkey

16.5

101

Saint Vincent and the Grenadines

17.2

102

Egypt

18.6

103

Paraguay

18.7

104

Honduras

18.9

105

Trinidad and Tobago

19

106

Viet Nam

19

106

Ecuador

19.1

108

Fiji

20

109

Nicaragua

20

109

Suriname

20.3

111

Niue

20.7

112

Algeria

21.6

113

Kyrgyzstan

21.6

113

Democratic People's Republic of Korea

21.7

115

Cabo Verde

21.9

116

Philippines

23.5

117

Dominican Republic

23.6

118

Tuvalu

24.4

119

Indonesia

24.5

120

Solomon Islands

25.1

121

Guatemala

25.8

122

Morocco

26.1

123

Mongolia

26.4

124

Iraq

28

125

Bhutan

29.7

126

Micronesia (Federated States of)

29.8

127

Azerbaijan

29.9

128

Guyana

29.9

128

Nauru

29.9

128

Marshall Islands

30.6

131

Bolivia (Plurinational State of)

31.2

132

Nepal

32.2

133

Cambodia

32.5

134

South Africa

32.8

135

Bangladesh

33.2

136

Namibia

35.2

137

Congo

35.6

138

Eritrea

36.1

139

Botswana

36.3

140

United Republic of Tanzania

36.4

141

Sao Tome and Principe

36.7

142

Uzbekistan

36.7

142

Rwanda

37.1

144

Gabon

39.1

145

Madagascar

39.6

146

Myanmar

39.8

147

Yemen

40.4

148

Tajikistan

40.9

149

India

41.4

150

Uganda

43.8

151

Senegal

43.9

152

Malawi

44.2

153

Ethiopia

44.4

154

Kiribati

45.1

155

Timor-Leste

46.2

156

Turkmenistan

46.6

157

Papua New Guinea

47.3

158

Kenya

47.5

159

Gambia

49.4

160

Sudan

51.2

161

Ghana

52.3

162

Liberia

53.6

163

Lao People's Democratic Republic

53.8

164

Haiti

54.7

165

Burundi

54.8

166

Zimbabwe

55

167

Togo

55.8

168

Zambia

55.8

168

Swaziland

55.9

170

Benin

56.2

171

Djibouti

57.4

172

Comoros

57.9

173

Niger

59.9

174

Cameroon

60.8

175

Mozambique

61.5

176

Burkina Faso

64.1

177

South Sudan

64.1

177

Guinea

64.9

179

Mauritania

67.1

180

Pakistan

69

181

Equatorial Guinea

69.3

182

Afghanistan

70.2

183

Côte d'Ivoire

71.3

184

Lesotho

73

185

Nigeria

74.3

186

Mali

77.6

187

Guinea-Bissau

77.9

188

Democratic Republic of the Congo

86.1

189

Chad

88.5

190

Somalia

89.8

191

Central African Republic

96.1

192

Angola

101.6

193

Sierra Leone

107.2

194

 

Life Expectancy

Years at birth

 

Country

Life Expectancy

Rank

Japan

84

1

Andorra

83

2

Australia

83

2

Italy

83

2

San Marino

83

2

Singapore

83

2

Spain

83

2

Switzerland

83

2

Canada

82

9

Cyprus

82

9

France

82

9

Iceland

82

9

Israel

82

9

Luxembourg

82

9

Monaco

82

9

New Zealand

82

9

Norway

82

9

Republic of Korea

82

9

Sweden

82

9

Austria

81

20

Finland

81

20

Germany

81

20

Greece

81

20

Ireland

81

20

Malta

81

20

Netherlands

81

20

Portugal

81

20

United Kingdom of Great Britain and Northern Ireland

81

20

Belgium

80

29

Chile

80

29

Denmark

80

29

Lebanon

80

29

Slovenia

80

29

Costa Rica

79

34

Nauru

79

34

Qatar

79

34

United States of America

79

34

Barbados

78

38

Colombia

78

38

Croatia

78

38

Cuba

78

38

Czech Republic

78

38

Kuwait

78

38

Maldives

78

38

Bahrain

77

45

Bosnia and Herzegovina

77

45

Brunei Darussalam

77

45

Estonia

77

45

Panama

77

45

Peru

77

45

Poland

77

45

Suriname

77

45

United Arab Emirates

77

45

Uruguay

77

45

Argentina

76

55

Bahamas

76

55

Cook Islands

76

55

Ecuador

76

55

Montenegro

76

55

Oman

76

55

Saudi Arabia

76

55

Slovakia

76

55

Syrian Arab Republic

76

55

The former Yugoslav republic of Macedonia

76

55

Tunisia

76

55

Venezuela (Bolivarian Republic of)

76

55

Viet Nam

76

55

Antigua and Barbuda

75

68

Belize

75

68

Brazil

75

68

Bulgaria

75

68

Cabo Verde

75

68

China

75

68

Dominica

75

68

Hungary

75

68

Libya

75

68

Mexico

75

68

Niue

75

68

Paraguay

75

68

Saint Lucia

75

68

Serbia

75

68

Sri Lanka

75

68

Thailand

75

68

Turkey

75

68

Albania

74

85

Dominican Republic

74

85

Georgia

74

85

Honduras

74

85

Iran (Islamic Republic of)

74

85

Jamaica

74

85

Jordan

74

85

Latvia

74

85

Lithuania

74

85

Malaysia

74

85

Mauritius

74

85

Nicaragua

74

85

Romania

74

85

Saint Kitts and Nevis

74

85

Saint Vincent and the Grenadines

74

85

Seychelles

74

85

Cambodia

73

101

El Salvador

73

101

Grenada

73

101

Palau

73

101

Samoa

73

101

Algeria

72

106

Azerbaijan

72

106

Belarus

72

106

Guatemala

72

106

Vanuatu

72

106

Armenia

71

111

Bangladesh

71

111

Egypt

71

111

Indonesia

71

111

Morocco

71

111

Tonga

71

111

Trinidad and Tobago

71

111

Ukraine

71

111

Democratic People's Republic of Korea

70

119

Fiji

70

119

Iraq

70

119

Marshall Islands

70

119

Republic of Moldova

70

119

Kyrgyzstan

69

124

Micronesia (Federated States of)

69

124

Philippines

69

124

Russian Federation

69

124

Solomon Islands

69

124

Tajikistan

69

124

Uzbekistan

69

124

Bhutan

68

131

Bolivia (Plurinational State of)

68

131

Kazakhstan

68

131

Mongolia

68

131

Namibia

68

131

Nepal

68

131

Tuvalu

68

131

Kiribati

67

138

Sao Tome and Principe

67

138

Timor-Leste

67

138

India

66

141

Lao People's Democratic Republic

66

141

Myanmar

66

141

Pakistan

66

141

Ethiopia

65

145

Rwanda

65

145

Botswana

64

147

Eritrea

64

147

Gabon

64

147

Guyana

64

147

Madagascar

64

147

Senegal

64

147

Turkmenistan

64

147

Yemen

64

147

Ghana

63

155

Haiti

63

155

Mauritania

63

155

Sudan

63

155

United Republic of Tanzania

63

155

Comoros

62

160

Djibouti

62

160

Liberia

62

160

Papua New Guinea

62

160

Afghanistan

61

164

Gambia

61

164

Kenya

61

164

Malawi

60

167

South Africa

60

167

Benin

59

169

Burkina Faso

59

169

Congo

59

169

Niger

59

169

Uganda

59

169

Zimbabwe

59

169

Guinea

58

175

Togo

58

175

Zambia

58

175

Cameroon

57

178

Mali

57

178

Burundi

56

180

Equatorial Guinea

56

180

South Sudan

56

180

Nigeria

55

183

Guinea-Bissau

54

184

Mozambique

54

184

Somalia

54

184

Côte d'Ivoire

53

187

Swaziland

53

187

Angola

52

189

Chad

52

189

Democratic Republic of the Congo

52

189

Central African Republic

51

192

Lesotho

50

193

Sierra Leone

46

194

 

Total Health Expenditures

Percent of Gross Domestic Product

Country

Health Care Expenditures

Rank

Afghanistan

8.1

55

Albania

5.9

114

Algeria

6.6

90

Andorra

8.1

55

Angola

3.8

166

Antigua and Barbuda

4.9

139

Argentina

7.3

67

Armenia

4.5

148

Australia

9.4

32

Austria

11

14

Azerbaijan

5.6

120

Bahamas

7.3

67

Bahrain

4.9

139

Bangladesh

3.7

169

Barbados

6.8

83

Belarus

6.1

105

Belgium

11.2

12

Belize

5.4

125

Benin

4.6

145

Bhutan

3.6

170

Bolivia (Plurinational State of)

6.1

105

Bosnia and Herzegovina

9.6

30

Botswana

5.4

125

Brazil

9.7

26

Brunei Darussalam

2.5

185

Bulgaria

7.6

62

Burkina Faso

6.4

97

Burundi

8

57

Côte d'Ivoire

5.7

117

Cabo Verde

4.4

151

Cambodia

7.5

63

Cameroon

5.1

134

Canada

10.9

15

Central African Republic

3.9

163

Chad

3.6

170

Chile

7.7

60

China

5.6

120

Colombia

6.8

83

Comoros

5.8

116

Congo

4.1

157

Cook Islands

3.1

179

Costa Rica

9.9

22

Croatia

7.3

67

Cuba

8.8

45

Cyprus

7.4

66

Czech Republic

7.2

71

Democratic Republic of the Congo

3.5

173

Denmark

10.6

17

Djibouti

8.9

41

Dominica

6

108

Dominican Republic

5.4

125

Ecuador

7.5

63

Egypt

5.1

134

El Salvador

6.9

81

Equatorial Guinea

3.5

173

Eritrea

3

181

Estonia

5.7

117

Ethiopia

5.1

134

Fiji

4.1

157

Finland

9.4

32

France

11.7

8

Gabon

3.8

166

Gambia

6

108

Georgia

9.4

32

Germany

11.3

11

Ghana

5.4

125

Greece

9.8

24

Grenada

6.3

101

Guatemala

6.4

97

Guinea

4.7

143

Guinea-Bissau

5.5

123

Guyana

6.5

91

Haiti

9.4

32

Honduras

8.7

47

Hungary

8

57

Iceland

9.1

37

India

4

159

Indonesia

3.1

179

Iran (Islamic Republic of)

6.7

87

Iraq

5.2

132

Ireland

8.9

41

Israel

7.2

71

Italy

9.1

37

Jamaica

5.9

114

Japan

10.3

19

Jordan

7.2

71

Kazakhstan

4.3

153

Kenya

4.5

148

Kiribati

10.1

20

Kuwait

2.9

182

Kyrgyzstan

6.7

87

Lao People's Democratic Republic

2

188

Latvia

5.7

117

Lebanon

7.2

71

Lesotho

11.5

9

Liberia

10

21

Libya

4.3

153

Lithuania

6.2

103

Luxembourg

7.1

77

Madagascar

4.2

155

Malawi

8.3

53

Malaysia

4

159

Maldives

10.8

16

Mali

7.1

77

Malta

8.7

47

Marshall Islands

16.5

3

Mauritania

3.8

166

Mauritius

4.8

141

Mexico

6.2

103

Micronesia (Federated States of)

12.6

5

Monaco

4

159

Mongolia

6

108

Montenegro

6.5

91

Morocco

6

108

Mozambique

6.8

83

Myanmar

1.8

190

Namibia

7.7

60

Nauru

6.3

101

Nepal

6

108

Netherlands

12.9

4

New Zealand

9.7

26

Nicaragua

8.4

51

Niger

6.5

91

Nigeria

3.9

163

Niue

7.1

77

Norway

9.6

30

Oman

2.6

184

Pakistan

2.8

183

Palau

9.9

22

Panama

7.2

71

Papua New Guinea

4.5

148

Paraguay

9

40

Peru

5.3

130

Philippines

4.4

151

Poland

6.7

87

Portugal

9.7

26

Qatar

2.2

186

Republic of Korea

7.2

71

Republic of Moldova

11.8

6

Romania

5.3

130

Russian Federation

6.5

91

Rwanda

11.1

13

Saint Kitts and Nevis

6.4

97

Saint Lucia

8.5

50

Saint Vincent and the Grenadines

5.2

132

Samoa

7.5

63

San Marino

6.5

91

Sao Tome and Principe

6.9

81

Saudi Arabia

3.2

176

Senegal

4.2

155

Serbia

10.6

17

Seychelles

4

159

Sierra Leone

11.8

6

Singapore

4.6

145

Slovakia

8.2

54

Slovenia

9.2

36

Solomon Islands

5.1

134

South Africa

8.9

41

South Sudan

2.2

186

Spain

8.9

41

Sri Lanka

3.2

176

Sudan

6.5

91

Suriname

4.8

141

Swaziland

8.4

51

Sweden

9.7

26

Switzerland

11.5

9

Syrian Arab Republic

3.3

175

Tajikistan

6.8

83

Thailand

4.6

145

The former Yugoslav republic of Macedonia

6.4

97

Timor-Leste

1.3

191

Togo

8.6

49

Tonga

4.7

143

Trinidad and Tobago

5.5

123

Tunisia

7.1

77

Turkey

5.6

120

Turkmenistan

2

188

Tuvalu

19.7

1

Uganda

9.8

24

Ukraine

7.8

59

United Arab Emirates

3.2

176

United Kingdom of Great Britain and Northern Ireland

9.1

37

United Republic of Tanzania

7.3

67

United States of America

17.1

2

Uruguay

8.8

45

Uzbekistan

6.1

105

Vanuatu

3.9

163

Venezuela (Bolivarian Republic of)

3.6

170

Viet Nam

6

108

Yemen

5.4

125

Zambia

5

138

 

 

25 Year Perspective

Editor's Note: The following special review of changes in public health over a quarter of a century was prepared in 2014 for the 25th anniversary of the America's Health Ranking® Annual Report.

 

The America’s Health Rankings® Annual Report was first released in 1990. This was a time when the definition of health and the role of public health were rapidly evolving. It was 26 years after the landmark 1964 Surgeon General’s Report on Smoking and Health as well as 8 years before the Tobacco Master Settlement Agreement between attorneys general of 46 states and 4 of the largest tobacco companies. In this period, research supporting the connection between population health and socioeconomic factors expanded, entered mainstream discussion, and became increasingly accepted. Surgeon General Quote

Twenty-five years ago, this stimulating research and a distinguished expert panel formed the wellspring of the America’s Health Rankings® Annual Report. The Annual Report was built upon the WHO definition of health: “Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” It was based on the premise that determinants of health directly influence health outcomes. The model has evolved over the last 25 years, but its emphasis on health determinants remains, and today the determinants account for three-quarters of each state’s final ranking. The determinants are divided into 4 categories: behavior, community and environment, policy, and clinical care. 

The Annual Report compares each state’s health with that of all others states for a single year. The Annual Report does not track the progress of the nation’s overall health over time but provides a year-to-year snapshot of state heath. However, the measure premature death, defined as the number of years not lived by people who die before age 75, can be used to examine our nation’s health over the last 25 years as that measure strongly correlates with the final outcome score (r=0.92) of the overall rankings. While premature death is a good proxy for the nation’s health, it does not reflect quality of life.

Measures of Mortality

Premature Death

premature death

In the last 25 years, premature death decreased 20%, from 8,716 to 6,976 years lost before age 75 per 100,000 population. This improvement means an increase in years of productive life in the population. While premature death has decreased nationally, improvement differs greatly by state. In New York, in the last 25 years premature death improved 41%, from 9,754 to 5,737 years of potential life lost, whereas in Oklahoma premature deaths worsened 13%, from 8,551 to 9,654 years of potential life lost. Declines in infant mortality and cardiovascular deaths are 2 measures that contributed greatly to the decline in premature death over the last quarter of a century.

Infant Mortality

Infant mortality

Infant mortality has declined 41% over the last 25 years, from 10.2 to 6.0 deaths per 1,000 live births. While this improvement is notable and the result of decades of continued effort, US infant mortality lags far behind other developed countries and many middle-income countries. The improvement in US infant mortality varies geographically. For example, Alaska improved 58%, from 10.6 to 4.5 deaths per 1,000 live births in the last 25 years, while Ohio improved only 22%, from 9.9 to 7.7 deaths per 1,000 live births.

 

Cardiovascular DeathsCardiovascular Deaths

Cardiovascular disease remains the nation’s leading killer despite a steep decline in cardiovascular mortality over the last 25 years. In 1990, the US cardiovascular death rate was 405.1 deaths per 100,000 population. Today’s rate is 251.4 deaths per 100,000 population, a decline of 38%. The improvement in US cardiovascular deaths varies geographically. In the last 25 years, Minnesota improved 47%, from 350.6 to 184.7 deaths per 100,000 population, while Oklahoma improved only 23%, from 415.3 to 322.0 deaths per 100,000 population.

Cancer DeathsCancer deaths

The Annual Report has tracked cancer deaths since 1990. Since a peak in 1996, there has been a slow-but-steady decrease in cancer mortality, reflecting a decline in incidence of some cancers, like lung cancer, and improvements in cancer treatment. The population’s longer lifespan over the last 25 years and the overall aging of the population have masked some improvement in cancer mortality as more cancer occurs in older individuals. From 1996 to 2014, US cancer mortality declined 8%, from 205.5 to 189.9 deaths per 100,000 population. In this same time span, this advance varied geographically, with Maryland improving 16%, from 224.0 to 187.7 deaths per 100,000 population, and Oklahoma worsening 6%, from 202.4 to 214.1 deaths per 100,000 population.Cancer quotation

These gains occurred during a period of mixed social economic indicators, as shown by the prevalence of children in poverty.

Children in Poverty

 

After a decade of decline, in 2002 the prevalence of children in poverty rose for almost a decade from 15.8% to 21.4%. Fortunately, it has declined in the last few years. States experienced much of the same cyclic nature of children in poverty, however the magnitude of the cycles varies from state to state.

Health Determinants / Risk Factors

Key to improving overall health is reducing the leading causes of death, including tobacco use. Since 1990, tobacco use has dropped significantly, yet almost 1 in 5 adults (19.0%) still smoke regularly. In the early 1990s, more than 1 in 4 smoked – so there has been progress, albeit slow. It is especially encouraging to see the 0.3% annual decrease from 2003 through 2011. This rate of decline appears to continue from 2012 through 2014. (Changes in data-collection methodology between 1990 and 1991 and between 2011 and 2012 do not allow a comparison over all 25 years).Smoking trends

Smoking among adults with low educational attainment is disproportionately large throughout the United States. Nationally, the prevalence of smoking among adults with less than a high school education is 32% – 4 times the prevalence among adults with a college degree. The prevalence of smoking among those with less than a high school degree varies greatly from state to state, with it being 3.5 times higher in Alaska than in California. In no state is the prevalence of smoking among those with a high school degree or less significantly lower than those with a college degree.smoking rates by educational attainment

Even as we celebrate the decline in cigarette smoking, there is increasing concern about youth smoking tobacco using hookahs (water pipes for smoking) and about other forms of tobacco use such as smoking cigars as well as using smokeless tobacco and e-cigarettes. Reducing all tobacco use is important in reducing the impact of adverse inhaled chemicals and particulates on health.

LegendOur nation’s struggle with obesity continues and is a leading cause of preventable death in the United States. It has increased almost yearly since 1990. Obesity appears to be abating among the very young[1] and is identified as a “winnable battle” by the Centers for Disease Control and Prevention. The graph below shows US self-reported obesity as it climbs and approaches 3 of every 10 adults (29.4%). This increase varies geographically, with obesity in Colorado more than tripling from 6.9% of adults in 1990 to 21.3% in 2014 and not quite doubling in Florida, moving from 13.6% of adults in 1990 to 26.4% in 2014.Obesity trends

The prevalence of obesity varies with educational attainment. Obesity among college graduates is only two-thirds of the obesity rate among those with less education. Obesity is also strongly associated with income.disparity in obesity

Physical inactivity, defined as the lack physical activity by individuals outside the work environment, has stagnated at the level of around 1 in 4 adults in the last few years. In an era when the work environment is becoming more sedentary, the need for physical activity and exercise outside the workplace is crucial in preventing and managing chronic disease.physical inactivity

Similar to obesity and smoking, inactivity varies by educational attainment. Making opportunities for activity part of each day for all adults -- regardless of work environment, educational attainment, or income -- will begin to address this disparity.Physical inactivity disparities

Increasing obesity has an ominous connection with the future prevalence of diabetes. The graph to the left parallels the graph above showing an increase in obesity. Self-reported diabetes has more than doubled in the last 20 years and is at 9.6% of the adult population. Furthermore, diabetes can be silent for years, and a lab test is required to positively identify. Thus, many cases go undiagnosed.[2] The increase in diabetes varies geographically; in Colorado the increase from 1996 to 2014 is 3% of the population, while in Alabama the increase in that same time span is 9%.Diabetes trends 1996 to 2014

 

Winnable battles

High School Graduation

High School Graduation 1990 to 2014A direct, upstream way to address the number of adults impacted by health disparities related to educational attainment is to improve education among teens. A more informed and educated populace creates greater opportunities for health across the population.

Graduation disparity by raceImprovements in the high school graduation rate have been consistent; there are now 9% more incoming freshman graduating 4 years later than in 2004. The current graduation rate of 81% is the highest in the last 25 years. Not all states have realized these gains since 2004. In Tennessee, there are 24% more incoming ninth graders graduating in 2014, and in Nevada, there are 10% fewer incoming ninth graders graduating in 2014. Unfortunately, not all races and ethnicities experience these improvements equally; graduation rates remain lower for blacks, Native Americans, and Hispanics compared with whites and Asians.

Violent Crime

Violent crime from 1990 to 2014Another bright spot in the nation’s health is the dramatic reduction in violent crime since the early 1990s. Violent crime is reduced almost 50% from its 1993 peak. This decline, however, does camauflauge the fact that homicide is still the leading cause of death among youth aged 10 to 24 years. Violent crime varies geographically, with 15 states experiencing an increase since 1990 -- led by the 168% increase in South Dakota. In New York, violent crime has dropped 60% since 1990.

Clinical Care

Preventable HospitalizationsSince 2001, preventable hospitalizations have declined 24% from 82.5 to 62.9 hospitalizations per 1,000 Medicare beneficiaries. In Mississippi, there are 37.7 fewer preventable hospitalizations per 1,000 Medicare beneficiaries in 2014 than in 2001 – a 32% decline. Louisiana has 35.3 fewer preventable hospitalizations per 1,000 Medicare beneficiaries in 2014 than in 2001 – a 35% decline.

Looking over the 25 years of health captured by the America’s Health Rankings® Annual Report, there are many accomplishments to celebrate. However, a lot of work remains so that we can all live up to our full life potential. Life expectancy at birth, while the highest it has ever been at 78.7 years, still lags other developed countries, leaving us substantial room for improvement. Another key challenge is that health gains are not experienced equally across the United States by state, race/ethnicity or educational attainment.


 

[1] Centers for Disease Control and Prevention. http://www.cdc.gov/obesity/data/childhood.html. Accessed October24, 2014.

[2] American Diabetes Association. http://www.diabetes.org/diabetes-basics/statistics/.0  Accessed October 24, 2014.

Downloads

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Annual Report Downloads

Americas Health Rankings - 2013 Edition
America's Health Rankings, 2013 Edition; A Call to Action for Individuals and Their Communities, released December 2013

Americas Health Rankings, 2013 Edition in Spanish
Americas Health Rankings, 2013 Edition in Spanish

Americas Health Rankings - 2014 Edition
America's Health Rankings, 2014 Edition; A Call to Action for Individuals and Their Communities, released December 2014

2014 Report in Spanish
2014 edition of America's Health Rankings, in Spanish.

2015 Annual Spanish Report
Informe Anual 2015 en Español

America's Health Rankings Annual Report 2015 Edition
America's Health Rankings, Annual Report, 2015 Edition released December 10, 2015