Executive SummaryIntroductionFindingsSmoking and Obesity- A Public Health Success and ChallengeExplore How the Prevalence of Obesity and Smoking Has ChangedComparison with Other NationsCore MeasuresBehaviorsCommunity & EnvironmentPolicyClinical CareOutcomesSupplemental MeasuresState SummariesAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingUS SummaryAppendixData Sources and MeasuresMethodology2016 Model DevelopmentScientific Advisory CommitteeThe TeamConclusion
The 2016 America’s Health Rankings Annual Report finds:
- Hawaii--for the fifth consecutive year--is the healthiest state.
- Iowa makes the biggest improvement in rank in one year, rising five spots from 22nd to 17th.
- Some states score much better in health determinants than health outcomes, which may have implications for future population health.
- There are national improvements in preventable hospitalizations among Medicare enrollees, smoking prevalence, and public health funding. High school graduation continues a three-year upward trend, and humanpapilloma virus (HPV) immunizations are increasing among male and female adolescents. Long-term improvements in health insurance coverage continue.
- A lack of decline in obesity prevalence and an increase in drug deaths remain ongoing challenges for the nation.
- Troubling increases in cardiovascular deaths and premature death are occurring. Cardiovascular deaths increased for the first time in the 27-year history of America’s Health Rankings.
Hawaii takes the title of the healthiest state in 2016, followed by Massachusetts (second). Connecticut (third) rises three spots this year to re-enter the top five. Minnesota (fourth) and Vermont (fifth) complete the top five (Tables 1 and 2, Figures 1 and 2).
Hawaii has ranked first for five straight years and has been in the top spot eight times since 1990, the most for any state in the history of America's Health Rankings. It has been in the top six states since the first edition of America’s Health Rankings in 1990. Hawaii also scores far better than other top-five states (Figure 1). Hawaii’s strengths include a low prevalence of obesity, a low percentage of people without health insurance, and a low rate of preventable hospitalizations. In addition, HPV immunization among females aged 13 to 17 years increased 38% from 38.0% to 52.4% in the past year. The prevalence of diabetes decreased 13% from 9.8% to 8.5% of the adult population.
All states have challenges and areas for improvement. Hawaii scores above the national average in the prevalence of excessive drinking and incidence of Salmonella, and below the national average for tetanus-diphtheria-acellular pertussis (Tdap) immunization among adolescents aged 13 to 17 years. These same challenges were identified in the 2015 America’s Health Rankings Annual Report.
Most Challenged States
Mississippi ranks 50th in 2016. Other states in the bottom five are Louisiana (49th), Arkansas (48th), Alabama (47th), and Oklahoma (46th) (Tables 1 and 2, Figures 1 and 2). West Virginia improves four spots this year to rise out of the bottom five. Mississippi has ranked in the bottom three states since the first edition of America’s Health Rankings in 1990. Mississippi and Louisiana score far worse than the other states in the bottom five (Figure 1).
Mississippi’s challenges include a high prevalence of smoking and low birthweight, and a high percentage of children in poverty. Mississippi ranks in the bottom 10 for 25 measures, including ranking in the bottom three for all measures of clinical care.
All states, no matter their overall ranking, have areas of strength. Mississippi ranks well for a low prevalence of excessive drinking and a low rate of drug deaths, as well as a small disparity in health status by education. Mississippi does better than the national average for low incidence of pertussis and low rate of violent crime.
*Weighted standard deviation relative to US value is listed vertically throughout the table.
Largest Changes in Rank Since 2015
Iowa is the most improved state, rising five spots from 22nd in 2015 to 17th in 2016 (Table 3). The state’s rise is due to improvements in the percentage of children aged 19 to 35 months and adolescents aged 13 to 17 years receiving recommended immunizations, including a 32% increase in HPV immunization among adolescent females. There are also improvements in pertussis incidence and public health funding.
Other states showing notable improvement this past year include West Virginia, Wisconsin, Connecticut, and Nevada. Wisconsin and West Virginia each rise four spots, and Connecticut and Nevada each rise three.
Maine has the largest decline in rank over the past year, moving from 15th in 2015 to 22nd in 2016. South Dakota’s rank falls five spots, and Alaska, Florida, and Vermont all fall three spots.
Determinants and Outcomes
For states to improve the health of their population, their efforts must focus on improving the determinants of health. If a state scores better on health determinants than it does on health outcomes, it may improve its health in the future. Conversely, if a state scores better on health outcomes than it does on health determinants, its health may decline.
Table 4 presents each state’s score for determinants, outcomes, and the implications for future health. If the difference between the determinants and outcomes scores (determinants greater than outcomes) is in the top 25% of all differences (75th percentile or above), the potential future effect on health is deemed positive and the state’s future health may improve. If there is little difference between the determinants and outcomes scores (difference in the second and third quartiles), the state’s future health is unlikely to change much and is labeled as a neutral effect. If the difference between the scores (outcomes greater than determinants) is in the bottom 25% of all differences, the effect is negative and the state's future health may decline.
Louisiana, Mississippi, New Mexico, Nevada, and Alaska all have determinants scores that are much lower than their outcomes scores (Table 4, Figures 3 and 4). In contrast, Vermont, Massachusetts, Connecticut, Rhode Island, and New Hampshire all have determinants scores that are much higher than their outcomes score.
- Smoking decreased 3% from 18.1% to 17.5% of US adults in the past year. Virginia and Arizona had a statistically significant decrease in smoking prevalence.
- In the past four years, smoking decreased 17% from 21.2% to 17.5% of the adult population.
Smoking and Obesity: A Public Health Success and Challenge provides an analysis of five-year trends in smoking and obesity, including variations by state and education level.
- Immunization coverage among children aged 19 to 35 months increased 6% in the past three years from 68.4% to 72.2%. There is still room for improvement before reaching the Department of Health and Human Services Healthy People 2020 target of 80% coverage.
- Among adolescents aged 13 to 17 years, 81.3% and 86.4% received meningococcal and Tdap immunizations in the past year, respectively. However, HPV immunization coverage is much lower than the other recommended adolescent immunizations; only 41.9% and 28.1% of females and males, respectively, received HPV vaccinations.
- HPV immunization coverage is improving. HPV immunization among males aged 13 to 17 years increased 30% in the past year, from 21.6% to 28.1%, though coverage among males still lags far behind HPV immunization among females. In the past two years, HPV immunization coverage among females aged 13 to 17 years increased 11% from 37.6% to 41.9%.
Health Insurance Coverage
- The percentage of people without health insurance decreased 19% from 13.1% to 10.6% in the past year. This is the lowest level in the history of America’s Health Rankings.
- Compared with 2011, the percentage of people without health insurance decreased 35% from 16.2% to 10.6% of the population.
- Preventable hospitalizations decreased 13% from 57.6 to 49.9 discharges per 1,000 Medicare enrollees in the past year.
- In the past 10 years, preventable hospitalizations decreased 35% from 77.0 to 49.9 discharges per 1,000 Medicare enrollees.
- The percentage of students graduating from high school increased 2% from 81.4% to 83.2% of students in the past year, continuing a three-year upward trend.
- Public health funding increased 9% from $86 to $94 per person over the past year.
- The prevalence of obesity remains high at 29.8% of the adult population and has not declined in the past year.
- The prevalence of obesity decreased in 25 states in the past year--although none of the decreases were statistically significant. It’s too early to determine if these are meaningful changes. Additional trend data are needed to determine if obesity has peaked in these states.
- The prevalence of obesity increased significantly in one state--Kansas--in the past year.
- In the past four years, obesity prevalence increased 7% from 27.8% to 29.8% of adults.
- Compared with 1990, obesity is 157% more prevalent among US adults. In 1990, 11.6% of adults were obese, compared with 29.8% now.
- One contributing factor to the rise in obesity prevalence is a long-term stagnation in physical inactivity. For the past 15 years, the prevalence of physical inactivity among adults has hovered around 25%. Increasing physical activity may be necessary to curb current trends in obesity.
- Drug deaths are becoming a greater concern for state, local, and national officials, as well as the communities they serve. The rate of drug deaths increased 4% from 13.5 to 14.0 deaths per 100,000 population in the past year. This continues to be a troubling trend.
- In the past five years, drug deaths increased 9% from 12.9 to 14.0 deaths per 100,000 population.
Sounding the Alarm: A Reversal of Long Term Trends?
The 27-year history of America’s Health Rankings can be used to examine the progress the nation has made to improve population health. The rankings also highlight when the nation’s health may be moving in the wrong direction. There are alarming changes in two measures that have been historically trending in a positive direction. It is important to call attention to these changes so that progress previously made is not further eroded.
Premature death has been largely declining since 1990. Between the 2005 and 2015 editions, the rate of premature death decreased from 7,564 to 6,997 years lost before age 75 per 100,000 population. However, in the past year, premature death increased for the second consecutive year, from 6,997 to 7,054 years lost before age 75 per 100,000 population. While the premature death rate has increased a few times during the history of America’s Health Rankings, this recent increase is important to monitor.
Reducing deaths from heart disease has been a major objective of the clinical and public health communities over the past few decades. Between 1990 and 2015, cardiovascular deaths have decreased 38% from 405.1 deaths to 250.8 deaths per 100,000 population. However, this year cardiovascular deaths increased for the first time in America's Health Rankings history, from 250.8 to 251.7 deaths per 100,000 population. While this may be a relatively small increase, it is statistically significant and is the first time since 1990 that an increase of any magnitude has occurred. It is important to watch for developing trends in key health outcomes so that individuals, communities, and officials can act to stem any erosion of our progress in improving population health.