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Healthiest States

Hawaii regains the title of healthiest state this year, after dropping to No. 2 in 2017. This is Hawaii’s ninth year in the No. 1 spot since 1990 when the health rankings were first published. The state has been No 1. four of the past five years. Massachusetts is No. 2, Connecticut No. 3, Vermont No. 4 and Utah No. 5. These same states ranked in the top five in 2017.
Hawaii’s strengths include:
  • Low prevalence of obesity at 23.8 percent of adults, compared with 31.3 percent nationally.
  • Low prevalence of smoking at 12.8 percent of adults, compared with 17.1 percent nationally.
  • Low disparity in health status with a 13.3 percentage point difference in high health status between those with and without a high school education, compared with 29.9 percentage points nationally.
  • Low levels of air pollution at 5.8 micrograms of fine particles per cubic meter, compared with 8.4 micrograms nationally.
  • Low prevalence of frequent mental distress at 9.5 percent of adults, compared with 12.4 percent nationally.
  • High number of primary care physicians at 187.6 per 100,000 population, compared with 156.7 per 100,000 nationally.
Despite Hawaii’s many strengths, the state faces these challenges:
  • 21.1 percent of adults report excessive drinking, compared with 19.0 percent nationally.
  • 84.8 percent of adolescents aged 13 to 17 received the Tdap vaccine, compared with 88.7 percent nationally.
  • 21.4 new cases of Salmonella per 100,000 population, compared with 16.7 per 100,000 nationally.
  • 10.9 percent of adults report they have diabetes, compared with 10.5 percent nationally.

Most Challenged States

Louisiana ranks No. 50 this year, replacing Mississippi as the state with the greatest challenges. Louisiana ranks No. 50 in both behaviors and community & environment categories, No. 47 in clinical care and No. 48 in health outcomes.
Louisiana’s challenges include:
  • Highest prevalence of children in poverty at 28.0 percent, compared with 18.4 percent nationally.
  • High prevalence of smoking at 23.1 percent of adults, compared with 17.1 percent nationally.
  • High prevalence of obesity at 36.2 percent of adults, compared with 31.3 percent nationally.
  • High prevalences of frequent mental distress and frequent physical distress at 16.1 and 16.5 percent of adults, respectively, compared with 12.0 percent for each nationally.
  • High percentage of low birthweight babies at 10.6 percent of live births, compared with 8.2 percent nationally.
Louisiana’s bright spots are:
  • High number of mental health providers at 271.9 providers per 100,000 population, compared with 234.7 per 100,000 nationally.
  • Low incidence of pertussis at 1.4 new cases per 100,000 population, compared with 5.6 per 100,000 nationally.
  • High HPV immunization coverage among females aged 13 to 17 at 64.3 percent, compared with 53.1 percent nationally.
  • High Tdap and meningococcal immunization coverage among adolescents at 90.1 percent and 89.0 percent, respectively, compared with 88.7 percent and 85.1 percent nationally.
Other states in the bottom five are Mississippi (No. 49), Alabama (No. 48), Oklahoma (No. 47) and Arkansas (No. 46). Oklahoma fell from No. 43, while West Virginia moved out of the bottom five to No. 44 this year.
Thirty-five measures are used to calculate the rankings (see Methodology). Of the 35 measures, 34 were updated in this edition and one measure’s source changed. The map in Figure 1 displays the 2018 rankings shaded by quintile. The healthiest states are in the Northeast, with a few states in the Midwest and West. States ranking least healthy are in the South with the exception of Indiana. Figure 2 shows each state’s score by rank. The difference between the highest and lowest scores is smaller than it was in 2017, indicating a narrowing of the gap between the top and bottom states. There is a large difference in score between Louisiana (-1.021) and Mississippi (-1.010) and No. 48 Alabama at -0.838, making it difficult for Louisiana and Mississippi to move out of the bottom two states. Table 1 lists the 2018 state rankings in alphabetical order.






*Weighted standard deviation relative to U.S. value. A score of 0 is equal to the U.S. value.

Largest Changes in Rank

Since 2017 Five states improved three or more ranks in the past year (Table 2), with Maine moving from No. 23 to No. 16. Maine’s behaviors measures rank improved from No. 29 to No. 21, and its community & environment measures moved from No. 8 to No. 2. These changes were driven by improvements in the state’s smoking and children in poverty ranks.
Oklahoma’s rank declined the most, dropping from No. 43 to No. 47. The state fell in behaviors from No. 37 to No. 44, a drop in rank driven mostly by increases in obesity and physical inactivity. Another seven states each dropped three ranks in the past year.

Since 2013

In the past five years, California improved from No. 21 to No. 12, and Virginia from No. 26 to No 20. Maryland, New York, Rhode Island and Washington each moved up five ranks (Table 3). Oregon fell from No. 13 in 2013 to No. 21 this year. Alaska dropped from No. 25 to No. 32 and Wyoming slipped from No. 17 to No. 24. Another four states each fell four places.

Since 1990

Since the debut of the annual health rankings in 1990, New York has risen from No. 40 to No. 10 this year, marking the greatest improvement of any state. Vermont, Maryland and California each rose more than 10 places to No. 4, No. 19 and No. 12, respectively. Wisconsin dropped from No. 7 to No. 23, while Oklahoma (No. 32 to No. 47) and Kansas (No. 12 to No. 27) both fell 15 places.

Model of Health Category Rankings

America’s Health Rankings Annual Report 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.” The model of health (Figure 3) used in this report has four categories of health determinants — behaviors, community & environment, policy and clinical care — that reflect the personal, social, and environmental factors that influence the fifth model category, health outcomes.
Table 4 shows that only five states rank in the same quintile across all five health categories. Hawaii, Massachusetts and Connecticut rank in the top 10 in all five categories, while Nebraska ranks in the second quintile and Mississippi in the bottom quintile across the five categories. Most states do not perform equally well across all categories of health. For example, Wyoming ranks in the top 10 for community & environment and health outcomes measures, near the middle for behaviors and clinical care measures and in the bottom 10 for policy measures. West Virginia ranks in the bottom 10 across behaviors, clinical care and health outcomes measures, yet ranks No. 5 for policy measures.
Figure 3. America’s Health Rankings model of health

National Successes and Challenges

Successes Summary

The percentage of children in poverty is decreasing.
  • The percentage of children in poverty decreased 19 percent from 22.6 percent in 2013 to 18.4 percent in 2018. It decreased 6 percent since 2017 from 19.5 percent of children aged 0 to 17.
The number of mental health and primary care physicians per 100,000 population are increasing.
Air pollution is decreasing.
  • Since 2015, air pollution decreased 12 percent from 9.5 to 8.4 micrograms of fine particles per cubic meter.
Adolescent immunizations are rising.
  • Since 2017, HPV immunization among males aged 13 to 17 significantly increased 18 percent from 37.5 percent to 44.3 percent. In the past year, HPV immunization among females aged 13 to 17 also increased 7 percent from 49.5 percent to 53.1 percent.
  • Meningococcal immunization significantly increased 4 percent from 82.2 percent to 85.1 percent of adolescents aged 13 to 17 in the past year. Since 2014, meningococcal immunization increased 9 percent from 77.8 percent of adolescents aged 13 to 17.

Challenges Summary

Obesity prevalence exceeds 30 percent of the adult population for the first time in America’s Health Rankings Annual Report history.
  • In the past year, obesity increased 5 percent from 29.9 percent to 31.3 percent of adults.
Premature death rates are increasing, impacted by the continuing rise in drug death and suicide rates and the increase in occupational fatalities.
  • In the past year, premature death significantly increased 3 percent from 7,214 to 7,432 years lost before age 75 per 100,000 population.
  • Since 2015, drug deaths increased 25 percent from 13.5 to 16.9 deaths per 100,000 population.
  • Since 2012, suicide increased 16 percent from 12.0 to 13.9 deaths per 100,000 population.
  • Since 2015, occupational fatalities increased significantly from 3.7 to 4.4 per 100,000 workers after decreasing from 5.3 in 2007 to 3.7 in 2015.
Frequent mental distress and physical distress are rising.
Cardiovascular death rates continue to move in the wrong direction.
  • Since 2015, cardiovascular deaths significantly increased 2 percent from 250.8 to 256.8 deaths per 100,000 population. The cardiovascular death rate has been increasing since 2015.
Cancer death rates show mixed results.
  • Since 1990, cancer deaths have significantly dropped 5 percent nationally from 199.0 to 189.8 deaths and decreased significantly in 19 states and the District of Columbia.
  • Over the same period of time, however, cancer death rates have increased significantly in 12 states and not changed in 19 states.
Chlamydia continues to increase.
  • Since 2009, chlamydia increased 35 percent from 367.5 to 497.3 cases per 100,000 population and 4 percent in the past year from 478.8 to 497.3 cases per 100,000 population.

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