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 ACS is an ongoing survey conducted by the U.S. Census Bureau that provides information on a yearly basis about population demographics and housing in the nation. Data are analyzed in single-year or five-year summations. Data can be accessed at data.census.gov.

Behavioral Risk Factor Surveillance System Data (BRFSS)

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, urbancity, education and income level. For calculating subpopulation estimates, the population of interest is specified in a manner that avoids 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 aged 18 and older. Discrepancies between prevalence estimates and population estimates are likely due to random sampling error and non-random response biases.

Estimates were suppressed if the denominator was less than 50 or the random standard error was greater than or equal to 30 percent. 

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 made two changes in 2011 to improve its survey methodology. Due to these changes, 2011 to 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 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 to 17 years. The surveys are sponsored and conducted by the National Center for Immunization and Respiratory Diseases (NCIRD) of the Centers for Disease Control and Prevention (CDC). Data are obtained from the ChildVax View and TeenVax View.

National Survey of Children's Health (NSCH)

The 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. It 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 aged 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. Missing values due to non-response or a “don’t know” response are not included in the denominator when calculating prevalence estimates and weighted population counts. 

The NSCH underwent a redesign in 2016. Data from the 2016 survey are not comparable to previous iterations of the NSCH and NS-CSHCN. The 2016 survey includes changes to data collection and sampling methods as well as the elimination or alteration of some survey questions. In addition, the NSCH and NS-CSHCN were also combined into a single self-administered questionnaire in 2016. 

National Survey on Drug Use and Health (NSDUH)

The NSDUH measures 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 (PDAS) or 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: ICD-10 codes: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 (PRAMS)

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 in which the response rate for the PRAMS survey does not meet the current threshold. For 2018 data, the threshold was a 50 percent 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. Several states (CA, ID, SD) do not participate in PRAMS but conduct similar surveys. When the questions and survey methodology were deemed to be consistent with PRAMS, those data are presented in this report.

More information on PRAMS can be found at the CDC website.

In 2021, the Centers for Disease Control and Prevention (CDC) committed to advancing health equity for everyone by addressing the impact of racism on health and the National Institutes of Health released a Minority Health and Health Disparities Strategic Plan 2021–2025.

This year, the 2021 America’s Health Rankings Senior Report added two disparity measures to convey the unequal distribution of health and prosperity by race and ethnicity among older adults in the United States, poverty racial disparity and early death racial disparity. Poverty among adults ages 65 and older and early death (death among those ages 65-74) both have well-known and persistent gaps by race and ethnicity. An additional perspective is provided when presenting the disparity measures alongside the prevalence measures. For example, states with a healthy rank for poverty rate but a poor rank for poverty racial disparity are reminded that the state poverty rate doesn’t reveal that not all races or ethnicities have a low poverty rate. 

The disparity values were calculated as the ratio between the race or ethnicity with the least healthy value and the value of the white population. A poverty racial disparity of 2.0, for example, would be interpreted as the poverty rate being 2 times higher among the race or ethnic group with the highest poverty rate compared with the poverty rate among the white population. For both measures, white was selected as the comparison group because it is the largest racial demographic group in nearly all states, which allows for a consistent reference group across states. The white subpopulation group has higher reliability and lower sampling error compared with other groups because of its size. This approach is often used by public health agencies such as the Agency for Healthcare Research and Quality and the Department of Health and Human Services when discussing health disparities by race and ethnicity.

The disparity measures are a reflection of the inequality between the white population and the group with the highest rate — not always a reflection of the disparity between the group with the healthiest value and the least healthiest value. States in which the white population has a relatively unhealthy value compared with other races and ethnicities, for example, may appear to have a small or no disparity. For the most comprehensive insights into the distribution of a measure within a state, please view data for all available races and ethnicities on the website.

Not all states have a large enough non-white population to calculate a disparity ratio. The values for these states are suppressed. For more information on suppression rules, see Data Sources. Where appropriate, the coefficient of variation (CV) is used to suppress estimates for races and ethnicities with high unreliability (CV ≥ 30) . These highly unreliable groups are excluded from the disparity calculation. Estimates with modest unreliability (CV ≥ 20) are included in disparity estimates. These estimates are noted on the website so they can be interpreted cautiously.

The race and ethnicity classifications in this report reflect those used by the data source and vary between measures. For example, data from the American Community Survey are non-Hispanic only for the white population, while the early death data from CDC are non-Hispanic for all races.

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 

CAPT Kathy Beasley, Ph.D. 
Director of Government Relations, 
Military Health Care 
Military Officers Association of America

Keith Boylan 
Deputy Secretary, Veterans Services 
California Department of Veterans Affairs

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

Kate Germano 
Chief Executive Officer
Cassandra-Helenus Partners

Dr. Ellen Haring, Ph.D., M.S 
Director, Service Women’s Institute 
Service Women’s Action Network

Dawn Jirak
Deputy Director, National Veterans ServiceVeterans of Foreign Wars

Kayda Keleher
Associate Director
Veterans of Foreign Wars

Gary Lee
Veteran Healthcare Advocate
U.S. Army Institute of Public Health

Rhonda Powell
Director, National Security Division
The American Legion

Keronica C Richardson
Assistant Director, Women & Minority Veterans Outreach
The American Legion

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

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

Dr. Barbara Van Dahlen, Ph.D. 
Founder and President 
Give an Hour

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


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

Carter Blakey 
Deputy Director, Office of Disease Prevention and Health Promotion 
Director, Division of Community Strategies, U.S. Department of Health and Human Services

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

Anne Edwards, M.D., F.A.A.P.
Senior Vice President Primary Care and Subspecialty Pediatrics, American Academy of Pediatrics

Carol Gilbert, M.S. 
Senior Health Data Analyst, CityMatch, The National Organization of Urban MCH Leaders

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

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. 
Director, Delaware Division of Public Health, State of Delaware

Carol Sakala, Ph.D., M.S.P.H. 
Director of Childbirth Connection Programs, National Partnership for Women and 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 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 definition of health: “Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.”

The understanding of population health has changed considerably over the past 30 years. Beginning in 2020, the America’s Health Rankings is transitioning to a new model that reflects a growing understanding of the impact social determinants have on health and the need for collaboration and action by stakeholders across sectors to reduce inequities and improve health outcomes.

The new 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.

Also new in 2020 are topics within categories. For example, substance use and physical activity and nutrition are two topics within the behaviors category. Category topics were created to group related measures, and therefore help derive additional insights, dialogue and action.

Four primary considerations drive the design of America’s Health Rankings® and the selection of the individual measures for each report:

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

Individual measures need to use common health measurement criteria.

Data have to be available at the state level.

Data have to be current and updated periodically.

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 provide guidance for the evolution of the rankings, balancing the need to change with the desire for comparability over time. Changes are being driven by: 

Acknowledgment that health is more than years lived but also includes the quality of those years

Data about the quality and cost of health care delivery are becoming available on a comparative basis

Measurement of additional determinants of health are being initiated and/or improved; and

Changes in collection methods to improve response rate and accuracy.

In addition to the measures that are used to rank states, each report and the website include numerous supplemental measures. These supplemental measures 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 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.

Geriatric providers. The definition was expanded to include nurse practitioners.

Severe housing problems. The new measure is limited to adults in one- or two-person households with an adult ages 62 and older.

Suicide. The definition is now calculated as a crude rate rather than an age-adjusted rate.

Voter participation (congressional). The name was changed from voter turnout — ages 65+. 

Model Topic and Measure Assignment Changes Behaviors

Substance use. This is a retired topic. Measures were relocated to tobacco use or behavioral health topics.

Tobacco use. This is a new topic. Health Outcomes

America’s Health Rankings releases three state ranking reports. 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:

Beyond the annual state rankings report, America’s Health Rankings has developed detailed analyses on the health of key populations in the country, including seniors, women and children, and those who have served in the U.S. Armed Forces. Each report is guided by an Advisory Committee that convenes annually to maintain currency in the field and to incorporate new or improved measures and methodologies. Advisory Committee members include representatives from state health departments, members of trade and advocacy organizations, as well as experts from a variety of academic disciplines.

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

Our mission is to provide a wide variety of health and health-related information to help policymakers, advocates and individuals understand a population’s health in a holistic, inclusive manner. 

The diverse set of measures included in America’s Health Rankings® reflect our belief that “health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (World Health Organization Charter). 

The Annual Report is the longest running annual assessment of the nation’s health on a state-by-state basis. For over thirty years, we have  analyzed a comprehensive set of population health data to provide a holistic view of the health of the people in the nation.

The Senior Report, first published in 2013, presents a comparative look at the health of older adults.

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

All three reports allow users to look at disparities in health by race/ethnicity, gender, age, education and income for a number of measures.

America’s Health Rankings also prepares a national report on active duty and veteran U.S. service members in partnership with the Military Officers Association of America. The Health of Those Who Have Served, first released in November 2016, explores the differences in health and health-related measures between those now serving or who have served in the military and the civilian population. These reports also highlight disparities among those who have served, including differences by age, gender, race/ethnicity, education and income.

In addition, America’s Health Rankings publishes 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 composite index of state-level population health measures. Each measure is ranked by the states’ values, with one being the healthiest value and 50 the least healthy value. Ties in value are assigned equal ranks. The states’ values for each measure are then normalized into a z-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. For measures positively associated with health, states with healthier values than the U.S. have a positive score, while states that perform below the U.S. have a negative score and vice versa for measures negatively associated with health. To prevent an extreme value from exerting excessive influence on the overall state score, the maximum score for a measure is capped at +/- 2.00.

The state health rankings are the ordering of the states according to their overall scores. A state’s overall score is calculated by adding the products of the score for each ranked measure multiplied by its assigned weight and impact (positive or negative) on health. 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.  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.

Represent a broad range of health topics that affect the health of the population.

Use common measurement criteria across the 50 states.

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