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Changes Implemented in 2015

  • Excessive Drinking replaced Binge Drinking as a core measure, and Chronic Drinking was added as a supplemental measure. Binge Drinking and Chronic Drinking are now separate supplemental measures. Substituting Excessive Drinking for Binge Drinking allows for discussing as health risks the frequency of drinking and the amount of alcohol consumed. Also, the definition of Excessive Drinking includes both binge and chronic drinking. Using the measure Excessive Drinking aligns America’s Health Rankings® Annual Report with County Health Rankings & Roadmaps, allowing for easier comparisons between publications.
  • Revised definition of High School Graduation. The National Center for Education Statistics (NCES) and all states have adopted the Adjusted Cohort Graduation Rate (ACGR) as the definitive measure of high school graduation. This measure is now preferred over the Average Freshman Graduation Rate (AFGR) for the following reasons: 1. The ACGR employs student-level data collected over a 5-year period and accounts for movement in and out of a cohort of students due to the transfer or death of students. 2. The AFGR, on the other hand, is a proxy rate indicator that is based on data available to NCES at the federal level (grade level aggregates by race/ethnicity and sex) and is a less comparable measure between states. It is still calculated because it is useful for trend analysis within a state. 3. The ACGR has been the standard for measuring graduation rates since 2011.
The ACGR is used in this edition to calculate the state ranking. As available, we will include AFGR as a supplemental measure.
  • The definition of Immunizations—Adolescents was revised. The National Immunization Survey doesn’t release a composite adolescent immunization coverage estimate as it does for the measure Immunizations—Children. When Immunizations—Adolescents was introduced in the 2013 America’s Health Rankings®, a composite value was calculated by averaging the percentage of adolescents aged 13 to 17 years who received 1 dose of tetanus, diphtheria, and acellular pertussis (Tdap) vaccine since the age of 10 years; 1 dose of meningococcal conjugate vaccine (MCV4); and females who received 3 doses of human papillomavirus (HPV) vaccine. However, because HPV immunization coverage estimates are much lower than Tdap coverage estimates, this method of combination misrepresents the percentage of teens who are fully vaccinated. To address this issue, we are including coverage estimates for the 3 individual vaccines to highlight the differences in coverage by vaccine. In addition, this year data became available for male HPV immunization coverage in all states except Mississippi. We averaged the female and male z scores to create a composite HPV vaccine coverage score. In this edition of America’s Health Rankings® Annual Report, Immunization-Adolescents was calculated as the average of the z scores for Tdap, MCV4, and combined HPV (female and male). The model weight for Immunizations—Adolescents (2.5%) is equally divided among Tdap MCV4 ( ), and HPV vaccine (composite of female and male coverage estimates).
  • Added Injury Deaths as a supplemental measure. Injuries, both unintentional and intentional, are a leading cause of morbidity and mortality in the US. Unintentional injuries are the fourth-leading cause of mortality, with accidental poisonings, motor vehicle accidents, and falls the top 3 contributors. Leading causes of intentional injury fatalities include suicide by firearm, homicide by firearm, and suicide by suffocation.

Possible Changes for 2016

Each year, we consider changes in the core model to reflect the evolving understanding of population health, to improve existing data sources, to integrate new data sources, and to adjust to changing availability of information. The following areas are being explored and will be discussed at the spring Scientific Advisory Committee (SAC) meeting:
Insufficient Sleep. The importance of slep as a public health issue is growing. The measure Insufficient Sleep will continue to be included as a supplemental measure, and its incorporation as a core measure will be re-examined at the spring SAC meeting.
Teeth extractions. Extraction of teeth due to disease is both an indicator of adverse current health conditions and a potential determinant of continued adverse health conditions in the future. Full extraction, limited extraction (6+ teeth), and extractions occurring before age 65 will be considered as an indicator of dental health.
Water fluoridation. Water fluoridation is considered a top-10 achievement in public health in the last century. [1] The prevalence of fluoridation in public water systems will be explored as an indicator of implementation of proven public health policy.
Sealants among Medicaid beneficiaries. The SAC will explore the prevalence of sealants among Medicaid beneficiaries as an indicator of clinical dental care in a challenged population.
Colorectal cancer screening. Colorectal cancer screening will be added as a supplemental measure during 2016. Incorporation of this measure into the core data set will be discussed at the SAC meeting.
Environmental pollution. The current measure Air Pollution does not fully address all avenues of pollution, especially water. This area will be explored for potential new measures to be included. Also, reconciling the differences in methodology between County Health Rankings & Roadmaps and America’s Health Rankings® Annual Report will be explored to reduce confusion among users.
All changes are explored using modeling to clarify the impact of any change. Final recommendations are made to the SAC in early spring. Approved recommendations are announced via our newsletter and social channels. If you wish to receive this information or if you have metric suggestions for America’s Health Rankings® Annual Report, contact us at In addition to the proposed changes, we continue to explore indicators that reflect the following areas of health: mental health, climate change, built environment, injury, diet, exercise, health equity, and socioeconomic status indicators.

Lack of Health Insurance

America’s Health Rankings® Annual Reportuses data from the US Census Bureau’s American Community Survey to calculate the percentage of the population that does not have health insurance. The data presented in this report were collected in 2013 and 2014 before full implementation of the Affordable Care Act.
[1], accessed October 21, 2015

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