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 (1990-2013) 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, with a body mass index (BMI) of 30.0 or higher. (2011 BRFSS Methodology)

Smoking

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

USA Smoking (1990-2013) see more
  • Percentage of adults who are current smokers.
  • Percentage of adults who are current smokers. (2011 BRFSS methodology)

Diabetes

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

USA Diabetes (1996-2013) see more
  • Percent 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?" Does not include pre-diabetes or diabetes during pregnancy. (2011 BRFSS Methodology)

Physical Inactivity

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

USA Physical Activity (1997-2013) see more
  • Percent of adults who indicated that they participated in physical activities during the past month.
  • Percent of adults who indicated that they participated in physical activities during the past month. (2011 BRFSS Methodology)

Health Disparities

 

The statewide measures used in America’s Health Rankings® reflect the condition of the “average” resident and can mask differences within the state. When the measures are examined by race, gender, age, educational attainment, and/or economic status, startling differences can exist within a state. For a population to be healthy, it must minimize health disparities among all segments of the population.

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]

America’s Health Rankings® contains an explicit metric for disparities. For the editions from 2008 to 2012, 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, America’s Health Rankings® replaces Geographic Disparity with a new measure, Disparity in Health Status. This indicator reflects the difference in self-reported high health status between adults aged 25 and older who did not graduate 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). This overall disparity metric provides a broad view of the challenges facing a state.

In addition, America’s Health Rankings® presents information on disparities within subpopulations in the prevalences of smoking, obesity, physical inactivity, diabetes, and high health status. The subpopulations of interest include education level, income level, race/ethnicity, gender, urbanicity, and age, where appropriate. The tabs below summarize the disparity for each of these metrics by education level. Disparities for the other subpopulations are available at the links immediately above.

Health status by education level varies from a high of 76.9 percent and 76.2 percent of college graduates aged 25 and older in the District of Columbia  and Vermont, respectively, who report that their health is very good or excellent to a minimum of 14.8 percent of adults aged 25 and older who did not graduate high school in Illinois. Within states, it varies from a difference of less than 35.0 percent among subpopulations reporting high health status in Alaska and Hawaii to more than a 50.0 percent difference among subpopulations in Illinois.

In a similar manner, the prevalence of smoking varies from a high of 44.8 percent of adults aged 25 and older who did not graduate high school in Michigan to a low of 2.6 percent of college graduates aged 25 and older in Utah. Within states, it varies from a difference of less than 15.0 percent of the subpopulations who smoke in California, Nevada, Hawaii, Arizona, and New York to more than a 35.0 percent difference in subpopulations who smoke in Wisconsin, Ohio, and Michigan.

The prevalence of physical inactivity varies from a high of 52.8 percent of adults aged 25 and older who did not graduate high school in Arkansas to a low of 6.7 percent of college graduates aged 25 and older in Colorado. Within states, it varies from a difference of less than 20.0 percent of the subpopulations who are physically inactive in California to a 38.0 percent difference in subpopulations who are inactive in Kentucky, Iowa, and Connecticut.

The prevalence of obesity varies from a high of 41.6 percent of adults aged 25 and older with some college in Louisiana to a low of 13.2 percent and 16.0 percent of college graduates aged 25 and older in the District of Columbia and  Colorado, respectively. Within states, it varies from a difference of less than 5.0 percent of the subpopulations who are obese in Alaska to more than a 20.0 percent difference in subpopulations who are obese in Oregon, Wyoming, and California.

America’s Health Rankings® uses the self-reported prevalence of diabetes as a metric within the outcomes section of the rankings. The tab below reports the disparity among education levels for diabetes. The prevalence of diabetes varies from a high of 21.6 percent and 21.3 percent of adults aged 25 and older who did not graduate high school in the District of Columbia Mississippi, respectively, to a low of 3.8 percent and 4.7 percent of college graduates aged 25 and older living in the District of Columbia and of Minnesota, respectively. Within states, it varies from a difference of 5.0 percent or less of the subpopulations who have diabetes in Nevada and Montana to an almost 15.0 percent difference in subpopulations who have diabetes in Virginia.

This type of analysis, especially when expanded to encompass a broader range of social, economic, and health indicators, allows communities, their organizations, and public health officials to target programs to address the biggest areas of concern.



[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.


A summary for each state is available here.
Health Status Smoking Physical Inactivity Obesity Diabetes

Health Status by Education and State

Percent of Population Aged 25 and Older Reporting Very Good or Excellent Health

State

Less than High School

High School Graduates

Some College

College Graduates

Alaska

35.0

45.5

51.8

66.9

Alabama

17.1

36.0

47.9

61.9

Arkansas

22.4

38.6

48.6

61.9

Arizona

19.1

45.9

49.9

65.2

California

21.2

46.9

56.2

69.1

Colorado

22.3

48.2

55.4

72.2

Connecticut

26.2

45.5

56.1

74.0

Delaware

23.8

46.6

52.2

67.3

Florida

20.9

42.1

55.0

67.0

Georgia

22.3

42.3

48.6

65.8

Hawaii

27.0

34.7

47.4

61.6

Iowa

25.2

46.0

56.7

70.7

Idaho

24.1

43.2

53.9

65.9

Illinois

14.8

39.8

49.6

69.0

Indiana

22.0

40.2

49.5

66.3

Kansas

27.3

44.4

53.5

68.2

Kentucky

18.2

36.4

48.7

62.9

Louisiana

21.9

38.0

48.0

63.0

Massachusetts

26.2

47.4

54.4

73.2

Maryland

26.1

44.7

56.3

69.4

Maine

27.9

47.2

56.3

74.0

Michigan

25.7

43.0

50.8

65.8

Minnesota

29.9

46.6

58.1

73.3

Missouri

23.7

43.1

51.9

64.6

Mississippi

22.1

35.2

46.1

61.6

Montana

26.7

44.7

54.9

71.2

North Carolina

21.2

40.3

52.8

68.4

North Dakota

24.5

43.7

54.7

66.3

Nebraska

22.8

43.6

53.7

67.7

New Hampshire

35.8

48.4

57.1

74.2

New Jersey

26.7

44.6

52.8

67.1

New Mexico

16.9

37.3

47.9

64.5

Nevada

21.5

43.1

50.8

65.5

New York

25.1

39.8

54.0

67.2

Ohio

22.4

41.7

51.1

68.7

Oklahoma

19.5

38.1

48.2

65.3

Oregon

28.1

43.2

51.5

69.9

Pennsylvania

26.5

44.4

53.3

69.6

Rhode Island

26.7

45.0

54.3

71.3

South Carolina

24.5

40.1

49.9

66.9

South Dakota

29.2

44.4

58.8

70.1

Tennessee

19.1

38.6

47.7

64.8

Texas

16.4

39.5

48.7

65.7

Utah

23.7

44.9

56.6

69.1

Virginia

23.3

40.5

52.9

67.8

Vermont

30.5

46.9

59.5

76.2

Washington

24.5

42.1

51.7

67.3

Wisconsin

28.6

47.4

52.8

67.2

West Virginia

17.6

35.0

45.1

64.7

Wyoming

31.3

46.1

58.9

69.3

United States

21.9

42.3

52.4

67.9

District of Columbia

32.7

43.2

57.2

76.9

Data Source: Behavioral Risk Factor Surveillance System, CDC, 2012.

Note: Self-reported health status for other subpopulations is available at www.americashealthrankings.org/ALL/health_status/disparities. Data are not age-adjusted.

 

Smoking by Education and State

Percent of Adults aged 65 and Older

State

Less than High School

High School Graduates

Some College

College Graduates

Alaska

40.8

27.1

20.2

6.2

Alabama

36.5

26.0

20.8

10.9

Arkansas

36.2

26.3

24.7

11.6

Arizona

21.1

22.8

17.3

8.3

California

15.7

18.7

13.8

5.7

Colorado

33.5

26.1

19.7

6.8

Connecticut

24.0

21.2

19.7

6.3

Delaware

32.7

23.8

20.1

8.3

Florida

26.9

21.4

17.3

8.5

Georgia

36.5

21.4

20.4

8.8

Hawaii

20.6

19.5

14.6

6.4

Iowa

31.4

20.3

20.8

7.3

Idaho

26.5

24.9

13.7

3.8

Illinois

27.3

23.5

22.7

8.2

Indiana

40.4

26.3

24.6

8.6

Kansas

30.8

23.7

20.0

8.9

Kentucky

43.6

30.2

26.0

12.7

Louisiana

38.7

26.9

24.5

11.6

Massachusetts

29.0

23.1

18.7

6.7

Maryland

30.6

23.0

17.2

6.4

Maine

35.5

25.6

18.6

7.4

Michigan

44.8

26.7

23.5

9.0

Minnesota

33.5

24.6

20.4

7.9

Missouri

43.2

26.1

25.6

9.4

Mississippi

37.1

25.8

23.1

9.3

Montana

38.6

23.1

18.3

8.2

North Carolina

31.1

26.4

21.7

8.1

North Dakota

33.5

26.3

22.0

9.3

Nebraska

33.2

23.1

20.4

9.1

New Hampshire

37.3

22.9

17.6

5.8

New Jersey

23.4

23.7

17.5

8.3

New Mexico

26.4

24.1

20.1

9.2

Nevada

23.2

23.9

16.9

10.4

New York

22.3

22.3

16.9

7.4

Ohio

44.3

26.7

23.1

8.2

Oklahoma

36.8

26.4

22.0

9.2

Oregon

33.3

23.1

18.8

6.5

Pennsylvania

38.2

24.0

22.2

8.6

Rhode Island

30.6

19.6

20.0

6.4

South Carolina

36.5

25.3

21.5

9.0

South Dakota

29.4

26.7

20.0

10.9

Tennessee

40.1

28.8

23.2

10.1

Texas

22.5

23.9

19.4

8.0

Utah

25.6

16.9

8.5

2.6

Virginia

31.7

25.5

19.4

8.0

Vermont

38.9

19.4

16.8

6.0

Washington

31.6

24.9

17.9

7.0

Wisconsin

44.4

23.4

20.6

7.0

West Virginia

39.1

28.8

27.4

12.9

Wyoming

40.8

23.7

22.9

7.2

United States

28.9

23.9

19.4

7.8

District of Columbia

41.1

34.3

20.9

8.1

Data Source: Behavioral Risk Factor Surveillance System, CDC, 2012.

Note: Smoking status for other subpopulations is available at www.americashealthrankings.org/ALL/Smoking/disparities. Data are not age-adjusted.

 

Physical Inactivity by Education and State

Percent of Adults Aged 25 and Older

State

Less than High School

High School Graduates

Some College

College Graduates

Alaska

34.4

28.4

15.1

11.1

Alabama

45.2

32.6

23.9

16.7

Arkansas

52.8

38.8

27.5

17.1

Arizona

40.6

26.7

22.4

13.9

California

28.8

23.8

16.9

11.2

Colorado

42.9

24.3

16.4

6.7

Connecticut

48.5

31.3

20.9

10.8

Delaware

40.8

29.8

23.5

11.8

Florida

42.7

30.0

21.8

12.5

Georgia

41.5

29.3

22.3

11.5

Hawaii

33.5

25.4

19.3

11.3

Iowa

49.0

32.2

22.1

11.1

Idaho

38.7

26.8

18.8

13.9

Illinois

33.9

30.3

21.8

12.3

Indiana

44.4

33.8

21.8

14.7

Kansas

49.3

32.1

20.9

12.0

Kentucky

52.7

34.2

26.3

14.8

Louisiana

49.5

35.8

27.5

15.2

Massachusetts

40.3

27.2

21.1

10.8

Maryland

45.7

29.5

21.3

12.8

Maine

45.4

26.7

19.8

9.9

Michigan

46.2

29.4

21.8

12.6

Minnesota

37.1

24.8

18.1

9.0

Missouri

43.1

32.0

24.4

12.9

Mississippi

51.5

36.6

26.3

18.3

Montana

34.7

27.7

21.7

10.6

North Carolina

44.7

33.1

22.2

12.3

North Dakota

44.2

32.4

23.3

15.0

Nebraska

33.7

29.8

20.9

11.4

New Hampshire

44.3

29.9

20.7

9.1

New Jersey

45.1

33.1

24.1

14.8

New Mexico

37.0

29.1

19.7

11.3

Nevada

33.2

28.7

17.4

12.2

New York

46.1

29.6

23.1

14.5

Ohio

47.8

33.6

22.3

12.3

Oklahoma

46.4

35.7

26.2

16.8

Oregon

32.7

23.2

15.5

6.9

Pennsylvania

43.8

30.4

22.8

10.9

Rhode Island

42.3

33.6

22.2

10.8

South Carolina

44.2

32.1

23.0

12.0

South Dakota

42.9

31.5

19.7

13.8

Tennessee

48.1

37.5

23.6

14.1

Texas

47.5

32.4

24.5

13.3

Utah

39.5

22.5

15.5

8.8

Virginia

43.6

31.3

22.2

12.7

Vermont

42.9

26.5

15.1

8.0

Washington

37.3

27.1

18.5

10.1

Wisconsin

35.8

25.5

20.6

10.9

West Virginia

47.7

35.6

27.4

15.9

Wyoming

36.5

30.2

19.0

13.5

United States

41.7

30.3

21.5

12.3

District of Columbia

38.4

30.4

18.1

8.4

Data Source: Behavioral Risk Factor Surveillance System, CDC, 2012.

Note: Self-reported physical inactivity for other subpopulations is available at www.americashealthrankings.org/ALL/Sedentary/disparities. Data are not age-adjusted.

 

Obesity by Education and State

Percent of Adults Aged 25 and Older

State

Less than High School

High School Graduates

Some College

College Graduates

Alaska

29.1

29.9

29.7

25.1

Alabama

37.1

35.4

35.7

28.6

Arkansas

37.9

37.7

34.4

31.9

Arizona

34.4

28.6

27.7

22.4

California

36.9

30.2

29.4

16.4

Colorado

28.0

24.9

24.1

16.0

Connecticut

37.2

31.9

33.7

17.8

Delaware

31.2

31.5

34.4

21.1

Florida

27.0

30.3

26.1

23.4

Georgia

30.7

35.5

35.1

24.2

Hawaii

30.1

30.2

24.7

16.9

Iowa

34.5

36.3

34.2

25.0

Idaho

33.6

27.6

31.4

24.8

Illinois

33.0

33.5

31.6

24.8

Indiana

41.4

34.6

35.0

24.7

Kansas

38.4

33.6

34.1

24.3

Kentucky

34.8

34.3

35.3

27.4

Louisiana

40.9

36.4

41.6

29.0

Massachusetts

33.7

28.7

28.2

16.7

Maryland

35.6

34.9

32.8

22.3

Maine

37.4

34.7

31.7

20.2

Michigan

33.3

36.4

35.1

25.8

Minnesota

36.5

30.6

30.0

19.5

Missouri

35.1

31.8

33.5

28.0

Mississippi

38.9

36.9

38.0

31.3

Montana

32.9

27.6

28.1

18.5

North Carolina

34.0

34.2

32.3

24.4

North Dakota

39.6

33.4

32.2

25.8

Nebraska

30.9

34.0

32.0

25.0

New Hampshire

38.5

32.6

31.9

21.1

New Jersey

34.7

29.5

28.7

19.0

New Mexico

35.0

29.9

31.4

19.3

Nevada

34.3

29.0

29.8

19.5

New York

34.4

26.1

26.7

18.9

Ohio

39.3

33.4

34.5

25.4

Oklahoma

34.5

34.8

36.3

26.1

Oregon

41.4

33.8

30.5

19.8

Pennsylvania

33.6

33.8

33.0

22.5

Rhode Island

30.2

32.0

29.4

21.0

South Carolina

40.9

34.8

35.3

24.8

South Dakota

35.5

32.9

30.9

23.5

Tennessee

36.6

34.0

37.0

26.0

Texas

37.4

34.3

32.6

24.3

Utah

30.1

28.5

28.2

22.3

Virginia

36.3

35.2

32.4

20.1

Vermont

28.6

31.3

26.9

16.8

Washington

36.2

32.7

31.0

20.9

Wisconsin

37.7

33.8

32.7

24.7

West Virginia

34.9

36.7

36.0

28.7

Wyoming

38.6

28.7

26.9

18.0

United States

35.3

32.5

31.4

21.9

District of Columbia

35.9

33.9

29.8

13.2

Data Source: Behavioral Risk Factor Surveillance System, CDC, 2012.

Note: Self-reported weight status for other subpopulations is available at www.americashealthrankings.org/ALL/Obesity/disparities. Data are not age-adjusted.

 

Diabetes by Education and State

Percent of Adults Aged 25 and Older

State

Less than High School

High School Graduates

Some College

College Graduates

Alaska

10.8

8.3

9.2

4.8

Alabama

17.5

16.1

12.5

9.3

Arkansas

15.3

13.5

12.5

8.6

Arizona

16.4

11.9

12.6

7.9

California

16.5

12.4

11.2

6.9

Colorado

14.6

10.0

8.9

5.0

Connecticut

18.5

12.8

10.9

5.6

Delaware

15.1

11.8

11.0

7.5

Florida

20.6

13.8

11.3

8.5

Georgia

16.2

12.5

10.6

7.5

Hawaii

14.6

9.4

9.4

5.5

Iowa

19.5

13.2

9.3

7.2

Idaho

17.1

9.2

10.5

6.1

Illinois

18.0

12.3

11.3

5.8

Indiana

20.2

14.3

10.9

7.3

Kansas

12.8

13.9

10.3

7.3

Kentucky

16.3

12.7

11.6

7.2

Louisiana

21.2

14.2

12.4

8.8

Massachusetts

15.7

13.0

9.5

5.2

Maryland

19.3

13.4

11.0

7.7

Maine

18.4

13.2

9.9

6.2

Michigan

17.8

13.8

11.3

7.4

Minnesota

16.1

10.7

7.7

4.7

Missouri

20.4

13.0

11.5

7.5

Mississippi

21.3

15.1

12.3

9.4

Montana

10.0

10.5

7.7

5.5

North Carolina

17.2

13.0

11.3

7.8

North Dakota

20.6

11.5

8.7

6.6

Nebraska

9.0

11.6

9.5

6.4

New Hampshire

19.7

12.9

10.3

5.9

New Jersey

16.2

12.0

9.9

7.6

New Mexico

17.8

12.0

11.1

7.7

Nevada

10.8

12.7

8.9

7.8

New York

20.0

12.6

10.9

5.8

Ohio

20.3

14.3

13.6

7.6

Oklahoma

17.5

14.2

12.0

10.1

Oregon

18.5

12.2

12.5

6.3

Pennsylvania

18.5

13.1

11.5

6.6

Rhode Island

15.5

12.3

11.5

7.7

South Carolina

20.7

14.3

12.8

7.2

South Dakota

14.3

10.6

7.7

5.9

Tennessee

19.6

13.5

13.6

8.7

Texas

16.6

13.7

11.7

7.9

Utah

12.3

9.4

8.7

6.1

Virginia

20.4

14.8

11.8

5.8

Vermont

12.9

10.7

7.0

4.9

Washington

12.0

11.8

10.7

6.7

Wisconsin

18.2

10.7

8.7

5.4

West Virginia

20.4

15.0

12.9

9.9

Wyoming

17.4

11.4

9.1

8.1

United States

17.7

13.0

11.1

7.0

District of Columbia

21.6

15.7

9.9

3.8

Data Source: Behavioral Risk Factor Surveillance System, CDC, 2012.

Note: Self-reported diabetes for other subpopulations is available at www.americashealthrankings.org/ALL/Diabetes/disparities. Data are not age-adjusted.

 

International Comparisons

When health in the United States is compared to health in other countries, the picture is disappointing. In an often cited report from 2000, the World Health Organization (WHO) ranked the US health care system 37th out of 191 nations in the world.[1] In WHO’s 2013 publication, World Health Statistics, the United States outperforms many countries on a variety of health-related measures, but it is far from the best in many of the key measures used to gauge healthiness and it lags behind its peers in other developed countries.[2] The latest updates on global health indicators by the WHO are at http://apps.who.int/nha/database/DataExplorerRegime.aspx.

On nearly all indicators of mortality, survival, and life expectancy, the United States ranks at or near the bottom among high-income countries.[3] Life expectancy is a measure that indicates the number of years a newborn is expected to live. Japan, San Marino, and Switzerland are the persistent leaders for developed countries in this measure, with an overall life expectancy of 83 years.2 Men of Qatar and women of Japan have the highest life expectancies of 83 years and 86 years, respectively.2 With a life expectancy of 81 years for women and 76 years for men, the United States ranks 33rd (36th for men and 35th for women) among the 193 reporting nations of the WHO2  The tab below lists a few other countries for comparison purposes. Life expectancy in the United States does not compare to most other developed countries as US male life expectancy rates are on par with Chile, Cuba, Brunei Darussalam, and Maldives.2 US female life expectancy rates are on par with Colombia, Costa Rica, Czech Republic, Estonia, Poland, and Qatar.

At a more granular level (ie, at the county level), US life expectancy rates appear even worse when compared to other leading nations.[4] While many US counties (33 counties for men and 8 counties for women) exceed the average life expectancy of the 10 leading nations, by far the majority of US counties lag behind these other nations. In fact, 92 US counties for men and 2 US counties for women have life expectancy rates similar to those experienced by other leading nations dating back to 1957 or earlier. Life expectancy rates in 1,406 US counties are now further behind those of developing nations than they were 7 years earlier.[4]         

Premature death contributes to lower life expectancy. For decades, the United States has experienced the highest infant mortality rate of high-income countries (see tab below).2 In 2011, the infant mortality rate in the United States was 6 deaths per 1,000 live births, ranking 40th among WHO nations.2 Infant mortality rates in Finland, Japan, and Sweden are one third the US rate. These countries also have considerably lower infant mortality rates than that of non-Hispanic whites in the United States, which is the ethnic/racial group with the lowest infant mortality rate. The persistent racial/ethnic disparities related to infant mortality within the United States could be related to differences in risk factors for infant mortality among different racial/ethnic groups (eg, risk for low birthweight delivery, socioeconomic status, access to medical care). However, many of the racial and ethnic differences in infant mortality remain unexplained.[5] It should be noted that the reporting and classification of infant mortality varies among countries, which may be reflected in the ranks.

In addition to infant mortality, deaths among youth and young adults impact life expectancy. Among US adolescents and young adults, unintentional injuries claim about 30 percent of the years lost before age 50, along with violence and suicides. Noncommunicable (chronic) diseases, such as heart disease, cancer, and other conditions not caused by infections, become more of a contributing factor after age 30.3

Differences in healthy life expectancy are also impacted by the effectiveness of treating disease, especially treatable diseases such as bacterial infections, certain cancers, diabetes, cardiovascular and cerebrovascular diseases, and complications from common surgical procedures. The age-adjusted amenable mortality rate before age 75 for the United States was 95.5 deaths per 100,000 population in 2006 to 2007.[6] Although this rate was down 25 deaths per year from 10 years prior, the rate of improvement was much slower than in other Organization for Economic Cooperation and Development (OECD) nations. The rate in the United States remains 50 percent higher than the rates in Australia, France, Japan, and Italy, reportedly contributing to 59,500 to 84,300 excess deaths before age 75 in the United States.[6]

Per capita health care spending in the United States continues to be the highest in the world. The median expenditure among OECD countries is around $3,000 per person. In the United States, it is more than $8,000 per person.7 The annual growth rate of spending in the United States from 2000 through 2010 was 4.3 percent, slightly under the average of 4.7 percent among OECD countries.[7] Utilization of health care in the United States also exceeds other OECD countries, with 25 percent of adults taking at least 4 prescriptions regularly compared to a median of 17 percent among studied countries. US patients receive 91 MRI exams per 100,000 population compared to fewer than 50 exams per 100,000 population in the other 5 reporting countries.[8]

The United States spends the most on health care, but this does not translate into better care for everyone, as the United States has one of the highest inequalities in health compared to other developed countries. The United States ranks among the worst OECD countries for child health well-being, having an inequality higher than average.[9] Although the United States has the highest national income per person, it continues to rank as the worst country for income inequality. This inequality is thought to explain why it has the highest index of health and social problems compared to other wealthy nations.[10]

Physical inactivity is a major contributor to disease worldwide and is the fourth leading risk factor for global mortality.[11] With roughly a third of the world’s population inactive, physical inactivity is responsible for an estimated 6 to 10 percent of non-communicable diseases such as heart disease, type 2 diabetes, breast cancer, and colon cancer. Overall it is responsible for 9 percent of premature deaths—5.3 million deaths in 2008.[12] It is estimated that eliminating physical inactivity in the United States could add nearly 1 year to life expectancy and dramatically reduce the burden of chronic diseases.[12]

Obesity is another major contributor to disease. North America has 34 percent of the world’s biomass due to obesity, yet it only makes up 6 percent of the world population. Asia, on the other hand, has 61 percent of the world population yet only 13 percent of its biomass due to obesity.[13] While the United States is only 1 of several countries that make up North America, they are the only North American nation to rank among the heaviest 10 globally.

Despite the highest per capita spending on health care (see tab below), the United States does not fare well in most comparisons to other developed countries. Key indicators of health and the health care system are substantially lower in the United States compared to other countries. The United States has some of the most state-of-the-art health care facilities, yet behavioral factors such as physical inactivity, smoking, and dietary choices, combined with inequalities, result in poor performance. Innovative solutions from the individual level to the national level are needed in order to address the health care challenges of today and the future.



[1] The world health report 2000 - health systems: Improving performance. Bulletin- World Health Organization. 2000;78:1064.

[2] World Health Organization (2013). World Health Statistics 2013.

[3] National Research Council (US), Institute of Medicine (US). US health in international perspective: shorter lives, poorer health. 2013. http://www.nap.edu/catalog.php?record_id=13497.

[4] Kulkarni SC. Falling behind: Life expectancy in US counties from 2000 to 2007 in an international context. Population Health Metrics. 2011;9(1):16. doi: 10.1186/1478-7954-9-16.

[5] MacDorman MF, and Mathews TJ. Recent Trends in Infant Mortality in the United States. Hyattsville, MD: US Dept. of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics; 2008.

[6] Nolte E. Variations in amenable mortality—trends in 16 high-income nations. Health Policy. 2011;103(1):47.

[7] Organization for Economic Co-operation and Development. OECD Health Data 2012.

[8] Squires DA. The US health system in perspective: A comparison of twelve industrialized nations. Issue Brief (Commonwealth Fund). 2011;16:1-14.

[9] UNICEF. The children left behind: A league table of inequality in child well-being in the world’s rich countries. Innocenti Research Centre: Report Card 9. 2010.

[10] Wilkinson RG, Prickett KE. Income inequality and social dysfunction. Annual Review of Sociology. 2009.

[11] World Health Organization. Global Health Risks Mortality and Burden of Disease Attributable to Selected Major Risks. Updated 2009.

[12] Lee I, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT. Effect of physical inactivity on major non-communicable diseases worldwide: An analysis of burden of disease and life expectancy. The Lancet. 2012.

[13] Walpole SC, Prieto-Merino D, Edwards P, Cleland J, Stevens G, Roberts I. The weight of nations: An estimation of adult human biomass. BMC Public Health. 2012.

 

Infant Mortality Life Expectancy Health Expenditures

Infant Mortality

Deaths per 1,000 live births

Country

Deaths per 1,000 live births

Rank*

Australia

4

22

Austria

4

22

Belgium

4

22

Canada

5

33

China

13

74

Czech Republic

3

9

Denmark

3

9

Finland

2

1

France

3

9

Germany

3

9

Greece

4

22

Hungary

5

33

Ireland

3

9

Israel

4

22

Italy

3

9

Japan

2

1

Mexico

13

74

Netherlands

3

9

New Zealand

5

33

Norway

3

9

Poland

5

33

Portugal

3

9

Spain

4

22

Sweden

2

1

Switzerland

4

22

United Kingdom

4

22

United States of America

6

40

*Rank among 194 member countries of WHO

Life Expectancy 

Years at birth

Country

Male

Rank*

Female

Rank*

Australia
80
4
84
9
Austria
78
24
84
9
Belgium
78
24
83
20
Canada
80
4
84
9
China
74
45
77
74
Czech Republic
75
41
81
35
Denmark
77
31
82
29
Finland
78
24
84
9
France
78
24
85
2
Germany
78
24
83
20
Greece
78
24
84
9
Hungary
71
78
79
50
Ireland
79
12
83
20
Israel
80
4
84
9
Italy
80
4
85
2
Japan
79
12
86
1
Mexico
72
63
78
56
Netherlands
79
12
83
20
New Zealand
79
12
83
20
Norway
79
12
83
20
Poland
72
63
81
35
Portugal
77
31
83
20
Spain
79
12
85
2
Sweden
80
4
84
9
Switzerland
80
4
85
2
United Kingdom
79
12
82
29
United States of America
76
36
81
35
*Rank among 194 member countries of WHO

Total HEALTH Expenditures

Percent of Gross Domestic Product

Country

Health Expenditure (%)**

Australia
9.03
Austria
10.64
Belgium
10.6
Canada
10.91
China
5.15
Czech Republic
7.38
Denmark
11.15
Finland
8.85
France
11.63
Germany
11.06
Greece
9.04
Hungary
7.75
Ireland
9.38
Israel
7.73
Italy
9.5
Japan
9.27
Mexico
6.14
Netherlands
11.96
New Zealand
10.08
Norway
9.07
Poland
6.74
Portugal
10.36
Spain
9.44
Sweden
9.36
Switzerland
10.86
United Kingdom
9.32
United States of America
17.98
**Total expenditure on health as % of gross domestic product   

 

National Changes

America’s Health Rankings® is a continuously evolving standard of comparing the relative health of the states. It combines publicly available data with an underlying model of population health to create a sound, reliable perspective on the overall health of a state’s population compared to other states and to the national average. In 2012, one of the underlying data sources for America’s Health Rankings® underwent significant changes and required a new baseline to be established with the 2012 Edition which is not longitudinally comparable to prior years. Also, many key individual metrics are not comparable to years prior to the 2012 Edition. However, some of the other individual components of the index are comparable over a longer period of time.

In the past year, 20 health measures improved, 8 measures declined, and 1 measure remained unchanged. This is based on an expanded core of 29 measures. For this comparison, infectious disease was expanded to its 3 sub-components—chlamydia, pertussis, and Salmonella—rather than treated as a single measure.

The next two tables show the measures that changed the most since the last edition and over a longer period of time.

National Successes and Challenges – Since the 2012 Edition

MEASURE

CHANGES

Successes

Smoking

The prevalence of smoking declined from 21.2 percent to 19.6 percent of adults who smoke regularly.

Binge Drinking

The prevalence of binge drinking declined from 18.3 percent to 16.9 percent of adults who binged in the last 30 days.

Physical Inactivity

The prevalence of physical inactivity declined from 26.2 percent to 22.9 percent of adults who did not participate in physical activity in the last 30 days.

Infectious Disease -Pertussis

The incidence of pertussis declined from 9.0 to 6.1 cases per 100,000 population.

Premature Death

The premature death rate declined by 2.4 percent from 7,151 to 6,981 years lost before age 75 per 100,000 population.

Challenges

Infectious Disease -
Chlamydia

The incidence of chlamydia increased by 8.0 percent from 423.6 to 457.6 cases per 100,000 population.

 

 

National Successes and Challenges – Long Term Changes

MEASURE

CHANGES

Successes

Preventable Hospitalizations

Preventable hospitalizations continue to decline. In 2001, there were 82.5 discharges per 1,000 Medicare enrollees; in 2013, there were 64.9 discharges per 1,000 Medicare enrollees.

Occupational Fatalities

Occupational fatalities have declined slightly in the last 6 years from 5.3 deaths in 2007 to 3.8 deaths per 100,000 workers in the 2013 Edition. Rates have reached a 23 year low.

Air Pollution

The average amount of fine particulate in the air continues to decline from 13.2 micrograms in 2003 to 10.3 micrograms per cubic meter in 2013.

Infant Mortality

The infant mortality rate decreased 39 percent from 10.2 deaths in 1990 to 6.3 deaths per 1,000 live births in the 2013 Edition, though most of that decline occurred between 1990 and 1999.

Premature Death

Since 1990, there has been a 20 percent decline from 8,716 to 6,981 years of potential life lost before age 75 per 100,000 population. Premature death, like several other metrics, has leveled off in the last decade compared to improvements in the 1990s.

Cardiovascular Deaths

Since 1990, cardiovascular deaths have declined 36 percent, from 405.1 deaths in 1990 to 258.7 deaths per 100,000 population in the 2013 Edition. This continues a relatively constant improvement of 2 percent to 3 percent each year.

Cancer Deaths

Cancer deaths declined 3 percent from 197.5 deaths in 1990 to 190.6 deaths per 100,000 population in the 2013 Edition.

High School Graduation

At only 78.2 percent of ninth graders graduating within 4 years, high school graduation is still a challenge. However, it is slowly trending upward from 71.7 percent in 2004.

Violent Crime

At 387 offenses per 100,000 population, violent crime is 36 percent lower than in 1990 and 49 percent lower than its peak in 1993.

Challenges

Children in Poverty

The percentage of children in poverty, at 21.3 percent of persons younger than 18 years, remains above 20 percent for the fourth straight year. This is far above the 23-year low of 15.8 percent in the 2002 Edition.

Lack of Health Insurance

The percentage of uninsured population increased 15 percent, from 13.9 percent 11 years ago to 15.6 percent, approximately the same as it was in the 2012 Edition. The percentage of uninsured population has remained relatively stable the last 4 years.

Immunization Coverage - Children

Nationwide, comprehensive immunization coverage among children aged 19 to 35 months is only 68.4 percent.

Low Birthweight

In the last 20 years, the prevalence of low birthweight infants has increased from 7.0 percent to 8.1 percent nationwide. The good news is that it appears to have leveled off in the most recent 7 years; however, a reversal to the 1990 level has yet to be observed.


In the last year, the prevalence of smoking declined in the United States from 21.2 percent to 19.6 percent of adults who smoke regularly (Graph 1). Seventeen states had a statistically significant decerease (p ≤0.05) in the prevalence of smoking between the 2012 and 2013 Editions are shown in the table below.

Graph 1: Smoking Since 1990
Trends in Smoking Since 1990


* The 2012-2013 data in the above graph is not directly comparable to prior years. See Methodology for additional information.

 


States with a Significant Decline in Smoking in the Past Year (p ≤0.05)

Prevalence of Smoking (percent of adults)

State

2012 Edition

2013 Edition

Change

Nevada

22.9

18.1

-4.8

Maryland

19.1

16.2

-2.9

Oklahoma

26.1

23.3

-2.9

Kansas

22.0

19.4

-2.6

Vermont

19.1

16.5

-2.6

Rhode Island

20.0

17.4

-2.6

Maine

22.8

20.3

-2.5

Montana

22.1

19.7

-2.4

Hawaii

16.8

14.6

-2.3

New Hampshire

19.4

17.2

-2.3

Iowa

20.4

18.1

-2.2

New Mexico

21.5

19.3

-2.2

Massachusetts

18.2

16.4

-1.9

New York

18.1

16.2

-1.9

Ohio

25.1

23.3

-1.8

Utah

11.8

10.6

-1.3

California

13.7

12.6

-1.1


The prevalence of obesity, a risk factor for numerous illnesses including diabetes and cardiovascular disease, appears to be leveling off after increasing for decades (Graph 2). Nationally, the prevalence of obesity is 27.6 percent of adults, essentially unchanged from 27.8 percent in the 2012 Edition.  It is too soon to predict if adult obesity will remain at this level, increase, or decrease in the future.

Graph 2: Obesity since 1990
Obesity trends since 1990
* The 2012-2013 data in the above graph is not directly comparable to prior years.  See Methodology  for additional information.


Potentially preventable hospitalizations (hospitalizations that may be preventable with high quality primary and preventive care) have declined over the last 12 years from 82.5 to 64.9 discharges per 1,000 Medicare enrollees (Graph 3). Preventable hospitalizations reflect how efficiently a population uses the various health care delivery options for necessary care. Hospital care is expensive and makes up the largest component of health care spending in the United States, totaling over $750 billion. Preventable hospitalizations often occur as a result of a failure to treat conditions early in an outpatient setting due to limited availability. These rates are also highly correlated with general hospitalization rates and reflect the tendency for a population to overuse the hospital setting as a site for care. Preventable hospitalizations place a financial burden on health care systems as they could have been avoided with earlier, less costly interventions. Preventable hospitalizations are more common in those who are uninsured, which often leads to large unpaid medical bills.

Graph3: Preventable Hospitalizations Since 2001
Preventable Hospitalizations Trends


Deaths from cardiovascular disease have consistently declined by 2 percent to 3 percent per year for the last decade (Graph4), a notable accomplishment of the health care system, despite increasing risk factors such as obesity, high cholesterol, and high blood pressure. Cardiovascular disease accounts for 17 percent of medical spending, 30 percent of Medicare spending, and totals nearly $150 billion annually.

Graph 4: Cardiovascular Deaths Since 1990
Trends in Cardiovascular Deaths


The difficult economic climate increases the challenge of maintaining a healthy population. Graph xxx depicts the continuing high percentage of children in poverty, increasing from 16.1 percent of children in the 2001 Edition to 21.3 percent of children in the 2013 Edition. The historic low of 15.8 percent of persons younger than 18 years was recorded in the 2002 Edition. Children in poverty is an indication of the lack of access to health care, including preventive care, for this vulnerable population.

Graph 5: Children in Poverty Since 2001
 Children Poverty Rate Trends


Infant mortality improved significantly in the 1990s but has largely stagnated between 6.5 and 7.0 deaths per 1,000 live births for the last 10 years (see Graph 6). The nation’s overall infant mortality rate is consistently higher than other developed countries, and significant racial and ethnic disparities exist.

Graph 6: Infant Mortality Since 1990
Infant Mortality Rate


For the last 6 years, between 8.1 percent and 8.3 percent of all infants were born with a low birthweight (<2,500 grams or 5 pounds, 8 ounces). This is up from 7.0 percent in 1993 (Graph 7).
Babies born with low birthweight are often born preterm or have inadequate growth for other reasons. Low birthweight may occur as a result of inadequate clinical care during the prenatal period. Through regular clinical visits, the health of the mother can be assessed, health risks can be identified, and steps can be taken to improve the mother’s health and her risk for preterm birth. Low birthweight is associated with many characteristics of the mother such as smoking status, nutritional status, and psychosocial problems.

Graph 7: Low Birthweight Infants Since 1993
Low Birthweight

 

 

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The 2013 Annual Health Rankings report in epub format for iBooks and all iOS devices.

2013 Commentary- Fineberg
Three Great Tasks for Health: - Harvey Fineberg, MD, PHD President: Institute of Medicine

2013 Commentary- Greenlee
Measuring Elder Abuse, Neglect, and Exploitation: The Role of the Health Care Community. Kathy Greenlee, Administrator and Assistant Secretary for Aging, Administration for Community Living, US Department of Health and Human Services

2013 Commentary- Cline
A Convergence of Practices and Partnerships: Reducing the Smoking Rate in Oklahoma. Terry Cline PhD, Oklahoma Secretary of Health and Human Services, Oklahoma State Commissioner of Health, Oklahoma State Department of Health

2013 Commentary- Castro
How Strong Community Buy-In Helped Change the Course of San Antonio and its Health. Julian Castro, JD, Mayor, City of San Antonio, Texas

2013 Commentary- Condon
Making It Easier To Live Well In St. Louis. Mary Jo Condon, MPPA, Senior Director, Partnerships and Projects, St Louis Area Business Health Coalition

2013 Commentary- ACP
The ACA's Promise of Prevention. Michelle Kline, MPH, Associate. Steven Weinberger, MD, FACP, Executive Vice President and CEO, American College of Physicians

2013 Commentary- APHA
Health Insurance Leads to Healthy People. Georges Benjamin, MD, Executive Director, American Public Health Association

2013 Commentary- Sanchez Partners for Prevention
Improving Health Rankings through Evidence-Based Prevention. Eduardo Sanchez, MD, MPH, FAAFP, Chairman, Partnership for Prevention