Dennis P. Andrulis, Ph.D., M.P.H.
Senior Research Scientist, Texas Health Institute

Soo Borson, M.D. 
Professor, Clinical Family Medicine, University of Southern California
Professor Emerita of Psychiatry and Behavioral Sciences, University of Washington
Adjunct Researcher, Kaiser Permanente Southern California
Co-Lead, CDC BOLD Center for Early Detection of Dementia

Julie Bynum, M.D., M.P.H.
Margaret Terpenning Collegiate Professor of Internal Medicine
Professor, Geriatric and Palliative Medicine, University of Michigan
Associate Director, Health Policy & Research, Geriatric Center
Research Scientist, Institute of Gerontology

Maggie Carlin, M.P.H.
Senior Director, Research and Evaluation, Association of State and Territorial Health Officials

Regina Davis Moss, Ph.D., M.P.H., M.C.H.E.S.
Associate Executive Director of Health Policy and Practice, American Public Health Association

Tom Eckstein, M.B.A.
Principal, Arundel Metrics, Inc.

Jonathan E. Fielding, M.D., M.P.H., M.B.A., M.A.
Distinguished Professor of Health Policy and Management, UCLA Fielding School of Public Health
Distinguished Professor of Pediatrics, David Geffen School of Medicine at UCLA

Reem Ghandour, Dr.P.H., M.P.A.
Director, Division of Epidemiology, Office of Epidemiology and Research, Maternal and Child Health Bureau, Health Resources and Services Administration

Marjory Givens, Ph.D. 
Associate Director, University of Wisconsin Population Health Institute

Marthe Gold, M.D., M.P.H.
Logan Professor Emerita, CUNY School of Medicine

Rahul Gupta, M.D., M.P.H., M.B.A., F.A.C.P. 
Chief Medical and Health Officer, Senior Vice President, March of Dimes

Alyssa Malinski Erickson
Vice President, United Health Foundation

Glen P. Mays, Ph.D., M.P.H.F. 
Chair and Professor, Department of Health Systems, Management and Policy in the Colorado School of Public Health Colorado University Anschutz Medical Campus

Sarah Milder, M.P.H.
Principal, Arundel Metrics, Inc.

Jane M. Pennington, M.P.H.
Vice President, Internal Communications, OptumInsight and Optum Tech

Rhonda Randall, D.O.
Senior Medical Advisor to the United Health Foundation
Executive Vice President & Chief Medical Officer of UnitedHealthcare Employer & Individual

Patrick Remington, M.D., M.P.H.
Professor Emeritus, University of Wisconsin School of Medicine and Public Health

Barbara Resnick, Ph.D., R.N., C.R.N.P., F.A.A.N., F.A.A.N.P.
Professor of Nursing, University of Maryland
Sonya Ziporkin Gershowitz Chair in Gerontology

Anna Schenck, Ph.D., M.S.P.H.
Professor and Director of the Public Health Leadership Program, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill

Mary C. Selecky
Retired Secretary of Health, Washington State

Katie Sellers, Dr.P.H., C.P.H.
Senior Advisor for Strategy and Innovation, Maternal and Child Health Bureau

Kristin Shaw, M.P.H.
Principal, Arundel Metrics, Inc.

Terri Tanielian, M.A.
Senior Behavioral Scientist, RAND Corporation

Steven Teutsch, M.D., M.P.H.
Senior Fellow, USC Schaeffer Center for Health Policy and Economics
Adjunct Professor, UCLA Fielding School of Public Health

Carla E. Zelaya, Ph.D. M.Sc.
Health Statistician and Epidemiologist, Data Linkage Methodology & Analysis Branch, Division of Analysis and Epidemiology, National Center for Health Statistics, Centers for Disease Control and Prevention

Dennis P. Andrulis, Ph.D., M.P.H.
Senior Research Scientist
Texas Health Institute 

Maggie Carlin, M.P.H.
Senior Director, Research and Evaluation
Association of State and Territorial Health Officials

Regina Davis Moss, Ph.D., M.P.H., M.C.H.E.S.
Associate Executive Director of Health Policy and Practice
American Public Health Association

Leah Devlin, D.D.S., M.P.H. 
Professor of the Practice, Health Policy and Management
UNC Gillings School of Global Public Health
University of North Carolina at Chapel Hill

Marisa Domino, Ph.D. 
Professor, Health Policy and Management
UNC Gillings School of Global Public Health
University of North Carolina at Chapel Hill 

Tom Eckstein, M.B.A. 
Principal
Arundel Metrics, Inc.

Jonathan E. Fielding, M.D., M.P.H., M.B.A., M.A. 
Distinguished Professor in Residence of Health Policy and Management
UCLA Fielding School of Public Health 
Distinguished Professor of Pediatrics
UCLA David Geffen School of Medicine 

Marjory Givens, Ph.D.
Associate Director
University of Wisconsin Population Health Institute

Marthe Gold, M.D., M.P.H. 
Logan Professor Emerita
CUNY School of Medicine

Glen P. Mays, Ph.D., M.P.H. 
Professor and Chair, Department of Health Systems, Management and Policy
Colorado School of Public Health at Colorado University Anschutz Medical Campus

Sarah Milder, M.P.H. 
Principal
Arundel Metrics, Inc.

Rhonda Randall, D.O. 
Senior Medical Advisor to the United Health Foundation
Executive Vice President & Chief Medical Officer of UnitedHealthcare Employer & Individual

Patrick Remington, M.D., M.P.H.
Professor Emeritus
University of Wisconsin School of Medicine and Public Health

Thomas C. Ricketts, Ph.D., M.P.H. 
Professor of Health Policy and Administration and Social Medicine
UNC Gillings School of Global Public Health
University of North Carolina at Chapel Hill

Anna Schenck, Ph.D., M.S.P.H. 
Professor and Director of the Public Health Leadership Program
UNC Gillings School of Global Public Health
University of North Carolina at Chapel Hill 

Mary C. Selecky 
Retired Secretary of Health
Washington State

Katie Sellers, Dr.P.H., C.P.H. 
Senior Advisor for Strategy and Innovation
Maternal and Child Health Bureau

Kristin Shaw, M.P.H. 
Principal
Arundel Metrics, Inc.

Leiyu Shi, Dr.P.H., M.P.A., M.B.A
Professor, Department of Health Policy and Management, Johns Hopkins
University Bloomberg School of Public Health
Director, Johns Hopkins Primary Care Policy Center

Steven Teutsch, M.D., M.P.H. 
Senior Fellow, USC Schaeffer Center for Health Policy and Economics
Adjunct Professor, UCLA Fielding School of Public Health

Mylynn Tufte, M.B.A., M.S.I.M., R.N.
Senior Director, Population Health Practice Lead
Optum

The American Community Survey (ACS) is an ongoing survey conducted by the U.S. Census Bureau that provides information yearly about population demographics and housing in the nation. Data are analyzed in 1-year and 5-year summations. Data can be accessed at data.census.gov.

The pandemic created data collection challenges in 2020 data for many surveys, including the U.S. Census Bureau’s American Community Survey (ACS). The Bureau has advised not to make geographical comparisons with 2020 ACS estimates due to nonresponse bias. As a result, 2019 ACS data were repeated instead of using 2020 ACS data.

BEHAVIORAL RISK FACTOR SURVEILLANCE SYSTEM

The Behavioral Risk Factor Surveillance System (BRFSS) data are analyzed using STATA to account for the complex survey design. Responses of “refused”, “don’t know” or “not sure” are excluded from the analysis but are reflected in standard error and confidence interval estimates. Prevalence estimates are calculated by sex, age group, race/ethnicity, urbanicity, education and income level. For calculating subpopulation estimates, the population of interest is specified in a manner that avoids the deletion of cases; this ensures an accurate variance estimation.

Population estimates for measures from BRFSS are calculated using the specified survey weights and represent the non-institutionalized adult population ages 18 and older. Discrepancies between prevalence estimates and population estimates are likely due to random sampling error and non-random response biases.

Estimates are suppressed if the denominator was less than 50 or the random standard error was greater than 30%.

When multiple years of data from BRFSS are used to obtain an estimate, weights are adjusted to represent the average population over the multiple-year period.

BRFSS improved their survey methodology in 2011. Due to these methodology changes, 2011-present BRFSS data are not directly comparable to previous years.

CDC publishes prevalence estimates for the total adult population as the median value of the 50 states and the District of Columbia. This convention is also used for the America’s Health Rankings Annual Report. The estimates for all subpopulations are based upon the mean of all applicable records. The mean is also used for the following reports that feature specific population groups: America’s Health Rankings Health of Women and Children, America's Health Rankings Senior, America’s Health Rankings Health of Those Who Have Served and America’s Health Rankings Health of Women Who Have Served.

The National Immunization Surveys are a group of phone surveys used to monitor vaccination coverage among children 19 to 35 months, adolescents 13 to 17 years, and flu vaccinations for children 6 months-17 years. The surveys are sponsored and conducted by the National Center for Immunization and Respiratory Diseases of the Centers for Disease Control and Prevention. Data are obtained from the ChildVax View and TeenVax View.

The National Survey of Children’s Health (NSCH) is funded and directed by the Health Resources & Services Administration’s Maternal and Child Health Bureau. These data — reported by parents and guardians — provide information about children’s health and access to health care. The survey also collects information on family, neighborhood, school and social interactions. Population estimates for measures from NSCH are calculated using the specified survey weights and represent the non-institutionalized child population ages 0 to 17 years in the U.S. and in each state and the District of Columbia who live in housing units. Discrepancies between prevalence estimates and population estimates are likely due to random sampling error and non-random response biases. When calculating prevalence estimates and weighted population counts, missing values due to non-response or a “don’t know” response are not included in the denominator.

The National Survey on Drug Use and Health (NSDUH) measures the use of illegal drugs, prescription drugs, alcohol, tobacco, mental disorders, treatment and co-occurring substance use and mental disorders. Estimates of substance use and mental illness at the national, state and sub-state levels are available. NSDUH data also help to identify the extent of substance use and mental illness among different sub-groups, estimate trends over time, and determine the need for treatment services.

Data are obtained from the Public-use Data Analysis System and the State Data Tables and Reports website.

Vital statistics (birth and death) data are obtained through the CDC WONDER Online Databases. Overall mortality rates, such as child mortality, include all causes of death. For other measures, the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) codes used are defined below. The crude rate is used unless otherwise noted in the definition. Data are suppressed in all instances where there are less than 20 deaths.

Drug deaths: X40-X44, X60-X64, X85, Y10-Y14
Maternal mortality: A34, O00–O95, O98–O99 (excluded late maternal death codes O96-O97)
Suicide: U03, X60-X84, Y87.0

PREGNANCY RISK ASSESSMENT MONITORING SYSTEM

The Pregnancy Risk Assessment Monitoring System (PRAMS) is a joint research project by the Centers for Disease Control and Prevention (CDC) and state health departments to examine the health of mothers and infants. Surveys are completed by mothers who recently gave birth, and data on the mother’s pregnancy and her infant are collected. PRAMS is one of the only sources for such data on a state-by-state basis.

The CDC suppresses data from states where the response rate does not meet the current threshold. Beginning in 2018, the threshold was a 50% response rate. For states that collected PRAMS data but did not meet the reporting threshold for release by the CDC, state health departments were contacted directly and PRAMS data were requested for use in this report. California, Idaho and Ohio do not participate in PRAMS but conduct similar surveys. Those data are included when the questions and survey methodology are deemed consistent with PRAMS. More information about this survey can be found on the CDC PRAMS website.

The Health Disparities Advisory Committee provided expertise and guidance in the selection of measures and the design of the 2021 America’s Health Rankings Health Disparities Report.

Dr. Dennis Andrulis
Senior Research Scientist
Texas Health Institute   

U. Michael Currie
Chief Health Equity Officer
UnitedHealth Group 

Dr. Rahul Gupta
Chief Medical and Health Officer
March of Dimes 

Dr. Cynthia Lindquist
President 
Cankdeska Cikana Community College 

Dr. Judy Monroe
President and CEO 
CDC Foundation 

Dr. Rhonda Randall
Chief Medical Officer
UnitedHealthcare Employer & Individual

Dr. Elena Rios
President 
National Hispanic Medical Association 

Ms. Amanda Meyers
Military Officers Association of America
Director of Government Relations, Military Health Care

Dr. Carla Zelaya
Centers for Disease Control and Prevention - National Center for Health Statistics
Epidemiologist

CDR René Campos
Military Officers Association of America
Director of Government Relations, VA Health/Wounded Warrior Care

Mr. Gary Lee
Texas Veterans Commission
Health Care Advocacy Program Manager

Dr. Theresa Jackson Santo
U.S. Army Institute of Public Health
Public Health Scientist

Dr. Marianne Shaughnessy
U.S. Department of Veterans Affairs
Director, GRECC Programs

Mr. Tom Eckstein
Arundel Metrics
Principal

Honorable Linda Spoonster Schwartz
Vietnam Veterans of America
Treasurer 


Christina Bethell, Ph.D., M.P.H., M.B.A. 
Director of the Child and Adolescent Health Measurement Initiative
Professor, Bloomberg School of Public Health, Johns Hopkins University

Cheryl Clark, Dr.P.H., R.H.I.A.
Associate Director – Equity, Epidemiology and Evaluation, Association of Maternal & Child Health Programs

Anne Edwards, M.D., F.A.A.P.
Chief Medical Officer, American Academy of Pediatrics

Carol Gilbert, Ph.D., M.S. 
Assistant Professor, CityMatch & The Division of Child Health Policy, Department of Pediatrics, 
University of Nebraska Medical Center

Kay Johnson, M.P.H., Ed.M. 
President, Johnson Group Consulting, Inc.

Sarah Milder, M.P.H
Principal, Arundel Metrics, Inc.

Jane Pennington, M.P.H. 
Vice President, Internal Communications, OptumInsight and Optum Tech UnitedHealth Group

Karyl Rattay, M.D., M.S. 
Former Director, Delaware Division of Public Health, State of Delaware

Carol Sakala, Ph.D., M.S.P.H. 
Senior Director for Maternal Health, National Partnership for Women & Families

Anna Schenck, Ph.D., M.S.P.H. 
Professor and Director of the Public Health Leadership Program, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill

Kristin Shaw, M.P.H. 
Principal, Arundel Metrics, Inc.

Holly B. Shulman, M.A. 
Statistician, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention

Lee Warner, Ph.D., M.P.H.
Chief, Women’s Health and Fertility Branch, Centers for Disease Control and Prevention

America’s Health Rankings® is built upon the World Health Organization’s definition of health: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”

Understanding of the factors that contribute to population health has changed considerably over the past 30 years. In response to growing awareness of the impact of social determinants of health, America’s Health Rankings transitioned to a new model in 2020. The model reflects the need for collaboration and action by stakeholders across sectors such as education, environment, housing and transit to reduce inequities and improve health outcomes.

The America’s Health Rankings model was developed under the guidance of the America’s Health Rankings’ advisory council and committees, with insights from other rankings and health models, namely County Health Rankings & Roadmaps and Healthy People. The model serves as a framework for identifying and quantifying health drivers and outcomes that impact state and national population health.

The model contains topics within categories. For example, economic resources and social support and engagement are two topics within the social and economic factors category. Category topics were created to group related measures and therefore help derive additional insights, dialogue and action.

Beyond representing a broad range of issues that affect the population’s health, four primary considerations drive the design of America’s Health Rankings® and the selection of the ranking measures for each report. Ranking measures are determined by the following criteria:

Represent issues that affect population health. 

Use common measurement criteria across the 50 states.

For America’s Health Rankings to continue to meet its objectives, it must evolve and incorporate new information as it becomes available. The advisory committees guide the evolution of the rankings, balancing the need to change with the desire for comparability over time.

In addition to the measures that are used to rank states, each report and the website include numerous other measures that provide additional information about the health in a state.

Each year the America’s Health Rankings Annual Report model is evaluated to reflect the evolving understanding of population health, integrate new measures or data when appropriate and adjust to changing availability of information. Final recommendations are made to the Advisory Committee. In addition to the changes implemented this year, the Advisory Committee continues to explore new data sources that could enhance the Annual Report model of population health. Of particular interest are state-level measures of climate change, housing and transit.

The 2021 report includes 81 individual measures developed from 30 data sources. Data for 12measures are repeated from the last edition. For a list of measures, definitions and source details, see the Measures Table. Measures are grouped by model category and within categories by topic areas such as economic resources, preventive clinical services and behavioral health.

The colorectal cancer screening definition was updated to reflect new recommendations from the U.S. Preventive Services Task Force.

The race groups for low birthweight and low birthweight racial disparity were updated to reflect single-race categories (replacing the bridged-race categories).

The residential segregation measure was updated to reflect non-Hispanic white race groups (versus white, including Hispanic) and to reflect household-level (versus population-level) data.

The data source for risk-screening environmental indicator score revised its data. As a result, 2018 data were updated on the website to reflect this change.

The data source for transportation energy use changed from the State Transportation Statistics of the U.S. Department of Transportation to the State Energy Data System of the U.S. Energy Information Administration due to a revision by the original data source that also affected the past two years of data. Updated data are available on the website.

The data source for volunteerism changed from the Corporation for National & Community Service to the Volunteerism and Civic Engagement Supplement of the Current Population Survey. 

The measure voter participation previously reflected the midterm election. This year, with the release of 2020 presidential data, the measure was updated to represent an average of the past two national elections (a combination of midterm and presidential).

Data for these three new measures are available on the website only, along with all other measures not included in the calculation of overall, category and topic composite measures:

Fourth grade reading proficiency is the percentage of fourth grade public school students who scored proficient or above on the reading assessment. Source: U.S. Department of Education, National Center for Education Statistics, National Assessment of Educational Progress, 2019.

Homeownership is the percentage of housing units owned by the occupant. Source: U.S. Census Bureau, American Community Survey, 2019.

Homeownership racial disparity is the difference in homeownership rate between the non-Hispanic white population and the racial/ethnic population with the lowest rate (varies by state). Source: U.S. Census Bureau, American Community Survey, 2019.

This year’s America’s Health Rankings Annual Report introduces a new model that expands the influence of social determinants of health. The community and environment category was expanded into two categories: social and economic factors and physical environment. The policy category was dropped and measures from that area were reassigned to the other categories. Many measures from the prior model were retained and reassigned to a new model category as appropriate. The new model includes 74 measures from 20 data sources. Also new this year are health topics such as economic resources, tobacco use and physical health. For a list of current measures, definitions and source details, see the Measures Table and Data Source Descriptions.

New measures
Adverse childhood experiences
Avoided care due to cost
Climate policies
Colorectal cancer screening
Crowded housing (economic hardship index)
Dedicated health care provider
Dental visit
Dependency (economic hardship index)
Depression
Drinking water violations
Drive alone to work
E-cigarette use
Economic hardship index
Education — less than high school (economic hardship index)
Exercise
Flu vaccination
Food insecurity
Fruit and vegetable consumption
High-risk HIV behaviors

Model Revisions
High school graduation racial gap
High-speed internet
Housing with lead risk
HPV vaccination
Income inequality
Insufficient sleep
Low birthweight racial gap
Multiple chronic conditions
Non-medical drug use
Non-medical drug use - past month
Non-smoking regulation
Per capita income (economic hardship index)
Poverty (economic hardship index)
Premature death racial gap
Residential segregation
Risk-screening environmental indicators score
Severe housing problems
Teen births
Transportation energy use
Volunteerism
Voter participation (midterm)
Water fluoridation

Retired measures
Cancer deaths
Cardiovascular deaths
Cholesterol check
Disconnected youth
Disparity in health status
Fruits
Heart attack
Heart disease
Immunizations — adolescents
Immunizations — HPV females
Immunizations — HPV males
Infectious disease
Injury deaths
Median household income
Meningococcal immunization
Pertussis
Salmonella
Seat belt use
Stroke
Underemployment rate
Vegetables
Voter registration

Measure category assignment changes
High school graduation: from behaviors to social and economic factors
Occupational fatalities: from community and environment to social and economic factors
Public health funding: from policy to social & economic factors
Violent crime: from community and environment to social and economic factors
Air pollution: from policy to physical environment
Childhood immunizations: from policy to clinical care
Uninsured: from policy to clinical care
Chlamydia: from community and environment to behaviors
Excessive drinking: from behaviors to health outcomes
Low birthweight: from clinical care to health outcomes
Obesity: from behaviors to health outcomes

Data source or methodology changes
The following measures are not comparable to previous years’ data:
Childhood immunizations. Previously presented by survey year, the new measure is reported by birth cohort.
Drug deaths. Previously calculated using three years of data, the new measure uses single year estimates age-adjusted to the current year U.S. population.
Dental care providers. Previously provided by the American Dental Association, the new measure is calculated using data from the National Plan and Provider Enumeration System, and the definition has been expanded to include advanced practice therapists.
Preventable hospitalizations. Previously provided by the Dartmouth Atlas of Health Care, the new measure uses data from the Centers for Medicare & Medicaid Services, Mapping Medicare Disparities Tool.
Primary care providers. Previously provided by Redi-Data, Inc., the new measure is calculated using data from the National Plan and Provider Enumeration System, and the definition has been expanded to include physician assistants and nurse practitioners.
Uninsured. Previously calculated using two years of data, the new measure uses single year estimates.

Thirty-five measures are used to calculate the state health rankings. Two measures, Immunizations–Children and Preventable Hospitalizations, were not updated this year due to no new data being released by the source prior to October 16, 2019; the values and ranks of these two measures are the same as in the 2018 edition. National Immunization Survey-Teen measures are not comparable to prior editions due to a methodology change by the data source. For current measures, definitions and source details visit the Rankings Measures Table.

These measures are not included in the state rankings calculation but provide context and highlight current and emerging issues affecting the nation’s health. For current supplemental measures, definitions and source details visit the Supplemental Measures Table. 

2018 Annual Report
Core Measures added in 2018:

Children in poverty is now calculated from the American Community Survey. Previously the data came from the Current Population Survey Annual Social and Economic Supplement. The Census Bureau recommends using the American Community Survey over the Current Population Survey of Annual Social and Economic Supplement for state-level data as it has less variability. American Community Survey children in poverty data for the previous 10 years are available on the website.

Four measures were added to this year’s report to expand the community & environment measures available from America’s Health Rankings, including:

Adverse Childhood Experiences are stressful or traumatic events that affect children and have a lasting impact on health and well-being. This measure is defined as the percentage of children aged 0 to 17 who experienced two or more of nine types of adverse childhood experiences.  

Concentrated Disadvantage is a life course indicator used to measure community well-being. Living in communities of concentrated disadvantage can be harmful to children through poorer quality schools; exposure to concentrated environmental hazards such as lead; lack of safe outdoor recreational spaces; exposure to adverse childhood experiences such as violence; and reduced economic mobility. The measure is calculated using five census variables: percentage below poverty line, receiving public assistance, female-headed households, unemployed and younger than age 18. It is presented as the percentage of households located in census tracts with a high level of concentrated disadvantage.

Severe Housing Problems captures both the quality of housing through the lack of kitchen or plumbing as well as the affordability and availability of housing through cost-burden and overcrowding. Inadequate housing conditions can compromise both physical and mental health and cause or aggravate respiratory conditions and chronic disease.

Voter Registration represents one element of social engagement. Active social engagement is associated with better health and health outcomes. This measure is defined as the percentage of U.S. citizens aged 18 and older registered to vote in biennial national elections.

2017 Annual Report
Core measures added in 2017:

Mental Health Providers was added to the clinical care category of the model to broaden the definition of clinical care to include mental health care in addition to primary care and dental care. Mental Health Providers is defined as the number of psychiatrists, psychologists, licensed clinical social workers, counselors, marriage and family therapists, providers that treat alcohol and other drug abuse, and advanced practice nurses specializing in mental health care per 100,000 population. With the addition of this measure to the model, the clinical care category weight was redistributed equally between the five clinical care measures. The addition of this measure did not appreciably effect on the overall rankings.

Disconnected Youth was added as a supplemental community & environment measure. It is defined as the percentage of teens and young adults aged 16 to 24 who are neither working nor in school.

Neighborhood Amenities was added as a supplemental community & environment measure to represent the built environment. It is defined as the percentage of children aged 0 to 17 with access to parks or playgrounds, recreation or community centers, libraries or book mobiles, and sidewalks or walking paths.

Dedicated Health Care Provider was added as a supplemental clinical care measure. It is defined as the percentage of adults who reported having one or more people they think of as their personal doctor or health care provider.

Six+ Teeth Extractions was added as a supplemental measure to capture oral health outcomes. It is defined as the percentage of adults aged 45 to 64 who reported having six or more teeth extracted.

Lack of insurance was renamed Uninsured. The definition and data source remain the same.

Public Health Funding: This year, rather than an average of the 50 states and the District of Columbia as was presented in previous editions, the U.S. average was calculated using the U.S. total for each of the three funding categories included in the numerator. 

Immunizations-Adolescents, HPV Females & HPV Males: The Advisory Committee on Immunization Practices released updated human papillomavirus (HPV) vaccination recommendations in December 2016. A new two-dose schedule is recommended for females and males who initiate the vaccination series between ages 9 and 14. Three doses are still recommended for those who initiate the vaccination series at ages 15 through 26 and for immunocompromised persons. Based on the new recommendations, the HPV immunization measures are now defined as the percentage of adolescents aged 13 to 17 who are up to date on all recommended doses of HPV vaccine. The previous definition was based on the initial three-dose series recommendation.  

2016 Annual Report
Core measures replaced or amended:

Poor Mental Health Days and Poor Physical Health Days in the outcome category were replaced by Frequent Mental Distress and Frequent Physical Distress, respectively. The new measures capture the percentage of adults with severe and/or chronic mental or physical health issues and align with County Health Rankings. Frequent distress is intended to measure the percentage of adults in frequent poor health (14 or more days in the past 30 days), whereas poor health days reflect the average number of poor health days in the past 30 days. Poor Mental Health Days and Poor Physical Health Days data will continue to be updated and presented as  supplemental measures to provide continuity of data.

The definition of Primary Care Physicians was amended. The new definition is limited to active physicians, and includes those in general practice, family practice, obstetrics and gynecology (OB-GYN), pediatrics, geriatrics and internal medicine. The previous definition included total physicians in general practice, family practice, OB-GYN, pediatrics and internal medicine. The measure now aligns with County Health Rankings. Data were obtained from Redi-Data Inc, a licensed provider of American Medical Association (AMA). In prior years, data were obtained from the annually printed AMA now discontinued publication Physician Characteristics and Distribution in the U.S..

The calculation for Air Pollution was adjusted to correct an error for estimating average emissions in counties without monitors. The previous measure overstated air pollution in each state by 0.1 to 0.2 micrograms of fine particles per cubic meter.

These substitutions and adjustments did not have an appreciable effect on a state’s score or rank.
Supplemental measures added:

Colorectal Cancer Screening: Colorectal cancer is the third most commonly diagnosed cancer and the third-leading cause of cancer mortality in the United States. Colorectal cancer is easier to treat when detected early through screening. Screening also allows for removal of colorectal polyps before they become cancerous. Colorectal cancer screening is an indicator of preventive care and is an important part of clinical care targeted at early diagnosis and treatment of disease. 

Seat Belt Use: Seat belt use reduces the severity of injuries from motor vehicle accidents and reduces motor vehicle deaths. Young adults, adults living in rural areas, and men are less likely to wear seat belts. Seat belt use varies greatly by state.

Water Fluoridation: Community water fluoridation is an effective way of preventing dental caries--an infectious disease in which bacteria dissolve tooth enamel. Water fluoridation is considered a top 10 achievement in public health in the last century. This measure was added as an indicator for implementation of this proven public health policy.

2015 Annual Report
Core measures replaced or amended:

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. Adding Excessive Drinking allows for discussion of the health risks posed by the frequency of drinking and the amount of alcohol consumed. The definition of Excessive Drinking includes both binge and chronic drinking. Using the Excessive Drinking measure aligns with County Health Rankings.

The definition of High School Graduation was revised. 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: 

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.

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.

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

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®, a composite value was calculated by averaging the percentage of adolescents aged 13 to 17 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 included 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. The Immunization — Adolescents measure 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 the Tdap vaccine, meningococcal vaccine, and HPV vaccine (composite of female and male coverage estimates). 

Injury Deaths was added as a supplemental measure. Injuries, both unintentional and intentional, are a leading cause of morbidity and mortality in the United States. 

The 2022 Senior Report includes 62 unique measures from 21 data sources. Data for nine measures are the same as appeared in the last edition. For a list of current measures, definitions and source details, see the Appendix: Measures Table. The measures are grouped by model category and topic area. To explore the data, including subpopulation groups at the national or state level, see Explore Report Data.

Ranking measures (included in overall rank): 37

Additional measures (not included in overall rank): 14

Summation measures (category, topics, subtopics and overall): 21

Two COVID-19 vaccination measures from the CDC COVID Data Tracker (as of March 17, 2022) were added as non-ranking measures. 

COVID-19 vaccinations - Ages 65+: Percentage of adults ages 65 and older who were fully vaccinated, defined as having received the second dose in a two-dose COVID-19 vaccine series or one dose of the single-shot J&J/Janssen COVID-19 vaccine.

COVID-19 vaccinations - booster dose - Ages 65+: Percentage of fully vaccinated people ages 65 and older who later received another dose of any COVID-19 vaccine.

Updates were made to the following measures. Estimates for this year are not comparable to prior years. 

Cancer screenings: Methodology was updated to reflect new recommendations from the United States Preventive Services Task Force for colorectal cancer screenings.

Drug deaths: Definition was updated to represent drug deaths among adults ages 65 and older, as opposed to adults ages 65-74. 

Home health care workers: Denominator was previously adults ages 65 and older with a disability. This year, the denominator was updated to represent all adults ages 65 and older.

Multiple chronic conditions: Source was changed from the Centers for Medicare & Medicaid Services’ Research, Statistics, Data and Systems to its Mapping Medicare Disparities Tool.

Preventable hospitalizations: Methodology and definition were updated to reflect new Agency for Healthcare Research and Quality inclusion criteria for the indicator PQI 90, dropping dehydration as an ambulatory-care sensitive condition.

Volunteerism: Source was changed from the Corporation for National & Community Service to the Volunteerism and Civic Life Supplement of the Current Population Survey.

Voter participation (Average): Measure previously reflected the midterm election. With the release of 2020 presidential data, the measure was updated to represent an average of the past two national elections (midterm and presidential).

The new model includes 49 measures from 22 data sources. Data for nine measures are the same as appeared in the Senior Data 2020 Update. For a list of current measures, definitions and source details, see the Measures Table. The measures are grouped by model category and topic areas such as economic resources, preventive clinical services and physical health.

America’s Health Rankings releases three state health ranking reports each year. Each report provides a comprehensive look at the health of the population across the nation and on a state-by-state basis using a wealth of reputable data sources.

America’s Health Rankings reports are guided by Advisory Committees that convene periodically to maintain currency in the field and incorporate new or improved measures and methodologies. Advisory Committee members consist of public health practitioners, state health officials, researchers, academics and clinicians.

In addition to the report committees, an Advisory Council advises on the role of the America's Health Rankings platform as a source of information and insights to promote discussions of current and emerging public health issues and provide continuity across reports. 

America’s Health Rankings is a longstanding platform that builds on United Health Foundation’s work to help draw attention to the cornerstones of public health and better understand the health of various populations.

The platform is a demonstration of the United Health Foundation’s mission of helping build healthier communities, and reflects UnitedHealth Group’s commitment to help people live healthier lives.

As the longest running state-by-state analysis of our nation’s health, the platform provides actionable, data driven insights that stakeholders can use to effect change either in a state or nationally.

The United Health Foundation provides the platform to help policymakers, community leaders and health officials better understand the specific health concerns in their own communities so we can all work together to address health challenges.

America’s Health Rankings provides an analysis of national health on a state-by-state basis by evaluating a historical and comprehensive set of health, environmental and socioeconomic data to determine national health benchmarks and state rankings.

The platform analyzes more than 340 measures of behaviors, social and economic factors, physical environment and clinical care data. Data is based on public-use data sets, such as the U.S. Census and the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System (BRFSS), the world’s largest, annual population-based telephone survey of over 400,000 people.

America’s Health Rankings releases three state health ranking reports annually. Each report provides a comprehensive look at the health of the population across the nation and on a state-by-state basis using a wealth of reputable data sources:

The Annual Report is the longest-running annual assessment of the nation’s health on a state-by-state basis. For over 30 years, America’s Health Rankings has analyzed a comprehensive set of data to provide a holistic view of the nation’s health.

The Senior Report, now with 10 years of data, presents a comparative look at the health of older adults.

The Health of Women and Children Report, first published in 2016, focuses on children and women of reproductive age. This report emphasizes the population groups where health improvements can make generational differences.

America’s Health Rankings also prepares a national report on active duty and veteran U.S. service members. The Health of Those Who Have Served, first released in November 2016, explores the differences in health and health-related measures between those who are serving or who have served in the military and the civilian population. All four reports allow users to look at disparities in health by race and ethnicity, gender, age, education and income for many measures.

In 2021, America’s Health Rankings released the Health Disparities Report. This report provides a comprehensive portrait of the breadth, depth and persistence of health disparities across the nation to provide objective data to inform action for advancing health equity. Building on over 30 years of data and reporting from America’s Health Rankings, this report provides objective data documenting the constant and changing contours of disparities for the nation, all 50 states and the District of Columbia by gender, geography, educational attainment and race and ethnicity.

In addition, America’s Health Rankings has published issue briefs and spotlights on special topics such as the Preparing for Health Care Costs in Retirement: An America’s Health Rankings Issue Brief, Spotlight: Impact of Unhealthy Behaviors and Spotlight: Prevention.

The state health rankings are a summation of select state-level population health measures. Ranks are calculated by state for each measure, ordered by the states’ values, with 1 corresponding to the healthiest value and 50 the least healthy value. Ties in value are assigned equal ranks. Model category and health topic ranks are summations generated to show how a state compares to other states for an entire topic, such as Economic Resources, or category, such as Social and Economic Factors. Overall state ranks indicate how a state compares to other states across all weighted measures in the index.

Overall, Model Category and Health Topic Calculations

The state value for each measure is normalized into a z-score, hereafter referred to as score, using the following formula:

The score indicates the number of standard deviations a state value is above or below the U.S. value. A score with the value of zero indicates a state has the same value as the nation. Scores are capped at +/- 2.00 to prevent an extreme score from excessively influencing the state's overall score.

Summation scores are calculated by adding the products of the score for each weighted measure multiplied by that measure’s relative assigned weight and association with health. Measures without weights are excluded from the overall, model category and health topic calculations. Measures positively associated with population health, such as high school graduation and flu vaccination, are multiplied by 1, while measures with a negative association, such as smoking and premature death, are multiplied by -1. Higher scores are associated with better health, and lower scores are associated with poorer health. The rankings are the ordering of the states according to their overall scores. If a state value is not available for a measure in an edition, the value from a prior edition is used; if no value is available for the prior year, the state’s score for the measure is set to zero. If a U.S. value is not available from the original data source for a measure, the mean of all states and the District of Columbia is used. For model category and measure weights, see Measures, Weights and Direction. It’s important to note that the rankings are a relative measure of health. Not all changes in rank translate into actual declines or improvements in health.

Data presented in America’s Health Rankings® reports are aggregated at the state level and cannot be used to make inferences at the individual level. The edition year reflects the year the report was released. The data are compiled from many different data sources and are referenced by the year the data were collected. In some instances, multiple years of data are combined in order to increase sample size and improve reliability of results. Values and rankings from prior years are updated on our website to reflect known errors or updates from the reporting source.

Subpopulation analyses are performed to illuminate age, gender, race and ethnicity, education, income and metropolitan status disparities. Not all subpopulations are available for all data sources and measures. Individual estimates are suppressed if they do not meet the reliability criteria laid out by the data source or by established internally. Some values have wide confidence intervals, meaning that the true value may by far from the estimate listed.

Gender. Data for females and males are reported as available through public data sources, even though not all people identified with these two categories. Data did not differentiate between assigned sex at birth and current gender identity. At the same time, sex and gender influence health, and the current data collection practices of many national surveys limit the ability to describe the health of transgender or gender nonbinary individuals.

Race and Ethnicity. Data are provided where available for the following racial and ethnic groups: American Indian/Alaska Native, Asian, Black or African American (labeled as Black), Hispanic or Latino (labeled as Hispanic), Native Hawaiian or Other Pacific Islander (labeled as Hawaiian/Pacific Islander), white, multiracial and/or those who identify as other race. Ethnicity was collected separately on surveys. People who identified as Hispanic or Latino may be of any race. Of note, racial groups are collected differently across data sources. For example, some sources combined Asian and Pacific Islander while other sources differentiated Asian from Hawaiian and Other Pacific Islander. In most data provided, the racial and ethnic groups are mutually exclusive, meaning all racial groups were non-Hispanic.

This committee provided expertise and guidance in the selection of measures and the design of the 2022 America’s Health Rankings Senior Report.

Soo Borson, M.D.
Professor, University of Southern California Keck School of Medicine
Professor Emerita, University of Washington
Co-Lead, CDC BOLD Center on Early Detection of Dementia
Adjunct Investigator, Kaiser Permanente Southern California

Julie Bynum, M.D., M.P.H.
Margaret Terpenning Collegiate Professor of Internal Medicine; Professor, Geriatric and Palliative Medicine; Associate Director, Health Policy & Research, Geriatric Center; Research Scientist, Institute of Gerontology; Vice Chair for Faculty Affairs
University of Michigan

Tom Eckstein, M.B.A.
Principal
Arundel Metrics, Inc.

Carol Irvin, Ph.D.
Senior Fellow and Director of Research
Mathematica Policy Research, Inc.

Senior Report Advisory Committee

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