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Health Equity

Equity is the absence of avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically or geographically.” World Health Organization
“Health disparities are the metric we use to measure progress toward achieving health equity. Moving toward greater equity is achieved by selectively improving the health of those who are economically/socially disadvantaged, not by a worsening of the health of those in advantaged groups.” Margaret Whitehead, World Health Organization
The America’s Health Rankings Annual Report examines health equity across the states. Measures of disparity are used to show progress at achieving health equity. This report uses the measure Disparity in Health Status to gauge the difference in self-reported high health status between adults aged 25 and older with less than a high school degree and adults aged 25 and older with a high school degree or more. High health status is defined as the percentage of adults reporting their health is very good or excellent.
This year's report continues to show a wide variation in Disparity in Health Status by state. In Alaska, there is only an 8.1 percentage point difference in the percentage of adults with a high school degree or more who report very good or excellent health status compared with those without a high school degree. Relative to other states, this is a small difference in high health status based on education level. In 12 states, the difference between the percentage of adults with at least a high school education and those with less than a high school degree reporting high health status is 30.0 percent or more.
Self-reported health status is a sound indicator of mortality and future use of health care services. According to a study in the International Journal of Epidemiology by medical sociologist and social demographer Amélie Quesnel-Vallée, populations with a higher health status tend to have lower overall mortality and use fewer health care resources.
Disparity in Health Status is an important, however, incomplete picture of inequity within states. It does not account for variation in high health status by gender, race/ethnicity, household income, urbanicity and additional education levels. The following section expands the discussion of health equity by reviewing additional disparities in high health status among these subpopulations.

Gender

Nationally, there is little difference between the percentage of males versus females reporting high health status (51.4 percent and 49.9 percent, respectively). Greater variation exists at the state level (Figure 34). In Texas, for instance, the percentage of males reporting high health status (50.5 percent) is significantly higher than females (43.2 percent). In Wisconsin and Vermont, the percentage of males reporting high health status (48.5 percent and 55.3 percent, respectively) is significantly lower than females (54.1 percent and 61.2 percent, respectively).
For males, high health status varies from 41.4 percent in West Virginia to 58.0 percent in Connecticut. Over the past five years, high health status among males in Wisconsin has significantly declined and in Montana it has significantly increased (Figure 35).
For females, the prevalence of high health status varies from 39.3 percent in Arkansas to 61.2 percent in Vermont. The change in the last five years for females is small at the national and state levels.

Race and Ethnicity

Figure 36 shows the prevalence of high health status by race and ethnicity groups. All race groups are non-Hispanic. The percentage of adults reporting high health status varies widely by race and ethnicity. For example, 56.2 percent of non-Hispanic Asian adults report high health status compared with only 37.9 percent of Hispanic adults.
When comparing prevalence of high health status by race/ethnicity at the state level, the difference between the group with the highest prevalence compared with the group with the lowest prevalence varies greatly (Figure 37). In Arizona, Vermont and Delaware, the difference is more than 40 percentage points. In Arkansas, New Hampshire, West Virginia and Tennessee, the difference is less than 10 percentage points. Note that compared to Arkansas, New Hampshire is closer to accomplishing the dual goals of obtaining a high prevalence of high health status as a state and minimizing the differences within the state by race/ethnicity.
Not all race/ethnicity groups were used in the state-level analysis. Only race/ethnicity groups with sufficient sample size in a state were compared. Values were suppressed if the sample size was less than 50 or the relative standard error was greater than 30 percent. For example, only Hispanics and whites are represented in Arkansas.

The prevalence of high health status increases with household income. Figure 38 shows that in the U.S., the prevalence of high health status among adults aged 25 and older with an income of $75,000 or more (68.0 percent) is 2.4 times the prevalence among households with an income of less than $25,000 per year (28.1 percent).
Figure 39 shows that Vermont has the largest gap in high health status at 47.9 percentage points between adults aged 25 and older with an income of $75,000 or more (76.8 percent) and adults aged 25 and older with an income of less than $25,000 per year (28.9 percent). Hawaii has the smallest gap in high health status at 22.5 percentage points between adults with the highest and lowest income levels.

Education

Nationally, the prevalence of high health status among adults aged 25 and older is statistically different at each education level (Figure 40).
The prevalence of high health status among U.S. adults aged 25 and older with a college degree is 66.8 percent. It varies from 58.6 percent of adults aged 25 and older in Alabama to 76.0 percent in the District of Columbia.
The prevalence of high health status among U.S. adults aged 25 and older without a high school degree is 22.6 percent. This is one-third of the prevalence among those with a college degree. It varies from 17.3 percent of adults aged 25 and older in West Virginia to 44.0 percent in Alaska.
North Carolina has the widest gap between adults aged 25 and older with a college degree, 70.0 percent, and those without a high school degree, 18.8 percent (Figure 41). Alaska has the narrowest gap, 71.4 percent versus 42.6 percent. The 10 states in Figure 41 show another characteristic of high health status that is true among all 50 states: the variation in high health status among adults aged 25 and older in the lowest education group is greater than those in the highest education groups. This suggests that where people live matters more for adults aged 25 and older with less than a high school education than those with higher education levels.

Urbanicity

High health status also varies by urbanicity. All three categories of urbanicity are significantly different from each other, with adults living in rural areas having the lowest prevalence of high health status at 42.2 percent (Figure 42).
There is variation among the 46 states that have population estimates in all three categories (Figure 43), but the variation is not as wide as with race, income or education.

Conclusions

Equity in health status is lacking at the national and state levels when viewed by race/ethnicity, gender, household income, urbanicity and education. Each state has a different profile of disparities in high health status. These profiles highlight the large challenge faced by states and the U.S. in reducing differences in health status related to economic and social disadvantage.

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