Executive BriefIntroductionDesignNational FindingsKey FindingsSocial and Economic FactorsPhysical EnvironmentClinical CareBehaviorsHealth OutcomesState SummariesAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingU.S. SummaryAppendixMeasuresData SourcesMethodologyNational Advisory CommitteeThe Team
The health and well-being of communities across America have improved significantly over the past century. Public health advancements, medical breakthroughs and increased access to health care have led to better health outcomes — and as a result, more Americans are living longer. However, health disparities continue to exist by gender, geography, socioeconomic status, race and ethnicity, and other factors. In some instances, disparities have grown in recent years, shortening lives and profoundly impacting our collective health and well-being.
For over three decades, America’s Health Rankings® has assessed the nation’s health and provided data-driven insights to support better health outcomes and build healthier communities. The inaugural America’s Health Rankings Health Disparities Report, produced by the United Health Foundation, documents the breadth, depth and persistence of health disparities across the nation to provide objective data to inform action for advancing health equity.
The COVID-19 pandemic exposed and exacerbated longstanding health disparities in the U.S. This report provides a first-of-its kind national and state-by-state portrait of the disparities in health and well-being that existed across the U.S. prior to the COVID-19 pandemic. In doing so, it sheds important new light on the difficult and disparate realities facing many Americans in the years leading up to the pandemic.
The America’s Health Rankings Health Disparities Report was developed with guidance from a National Advisory Committee — comprised of leading public health and health equity experts — who informed the selection of health measures and other methodological features of the report. Building on 31 years of data and reporting from America's Health Rankings, this new report provides objective data documenting the constant and changing contours of disparities for the nation, all 50 states and the District of Columbia by gender, geography, educational attainment, and race and ethnicity. The report's findings underscore the broad and deep nature of health disparities, while documenting their persistence over time, despite progress in some areas.
Model for Measuring America’s Health
America’s Health Rankings 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.”
Over the past three decades, the model and measures used in America’s Health Rankings have evolved as the understanding of health and the root causes of health outcomes have advanced.
This report analyzes 30 measures of health from four publicly available data sources: the American Community Survey (ACS), the Centers for Disease Control and Prevention’s (CDC) Behavioral Risk Factor Surveillance System (BRFSS), the Current Population Survey’s Food Security Supplement (CPS-FSS) and the National Vital Statistics System (NVSS). Depending on the source, three to five years of data were pooled across three time periods between 2003 and 2019 to produce reliable estimates. Time periods were selected based on data availability and, where possible, to have some consistency across measures. The measures included are indicators of social and economic factors, physical environment, clinical care, health behaviors and health outcomes.
The inaugural America’s Health Rankings Health Disparities Report provides a comprehensive portrait of the breadth, depth and persistence of health disparities across the nation:
- Breadth: Documents health disparities across 30 health-related measures that include core social and economic factors, clinical care indicators and physical environment, health behavior and health outcome measures critical to addressing health disparities and advancing health equity.
- Depth: Measures the magnitude of health disparities by educational attainment, gender, geography and race and ethnicity for the nation, all 50 states and the District of Columbia.
- Persistence: Identifies where health disparities have remained despite progress or lack thereof, and where they have grown over time.
While the country has made some notable health improvements in recent years, deep and widespread health disparities persist – and, in some instances, have grown.
Prior to the COVID-19 Pandemic, the Nation Made Progress in Several Key Health Measures. However, Not All Populations Experienced These Improvements Equally.
Uninsured Rate. Over the last decade, and prior to the COVID-19 pandemic, the national rate of uninsured declined 37%, from 14.6% to 9.2%, with all subpopulation groups experiencing improvements. Despite this progress, gaps remained between different population groups. For example, in 2015-2019 the uninsured rate was 3.5 times higher among individuals with only a high school degree (13.6%) than college graduates (3.9%) and 3 times higher among Hispanic individuals (18.5%) and American Indian/Alaska Native individuals (20.2%) than white individuals (6.2%).
In 2015-2019, the racial gap in rates of uninsured was particularly wide across states. American Indian/Alaska Native populations in Wyoming (who had the highest rate of uninsured in the U.S. – 38.4%) had a rate 24 times higher than the uninsured rate of white populations in the District of Columbia (who had the lowest rate in the U.S. – 1.6%).
Infant Mortality. In recent years, the U.S. made notable progress in reducing the racial gap in infant mortality. The infant mortality rate among Black infants decreased 19% from 2003-2006 to 2015-2018. However, Black infants (11.0 per 1,000 births) had the highest infant mortality rate — which was 2.8 times higher than Asian/Pacific Islander infants (4.0 per 1,000 births) — in 2015-2018.
During this period, progress varied substantially among states. Black infant mortality rates declined across 22 states and the District of Columbia, ranging from a 12% decline in Ohio to a 46% decline in Colorado. White, Asian/ Pacific Islander and Hispanic populations also experienced 11-16% declines in infant mortality rates during this time.
Severe Housing Problems. Before the COVID-19 pandemic, some progress was made in reducing the rate of severe housing problems, which includes: lack of kitchen or plumbing facilities, overcrowding or severely cost-burdened occupants. Between 2005-2009 and 2013-2017, households headed by Hispanic individuals experienced the greatest decline (11%) in severe housing problems, followed by households headed by Asian/Pacific Islander (8%) and Black individuals (5%).
Despite progress in reducing the percentage of households facing severe housing problems, households headed by Hispanic (29.9%), Black (25.3%) and American Indian/Alaska Native (24.2%) individuals had a rate of severe housing problems roughly 2 times higher than households headed by white (13.4%) individuals.
Wide Disparities in Mental Health and Chronic Disease Persist.
Mental Health. Over the years, deep and persistent disparities in mental and behavioral health have existed by gender, educational attainment and race and ethnicity — and have worsened for some subpopulation groups. Adults with less than a high school education (17.6%) had a rate of frequent mental distress that was 123% higher than college graduates (7.9%) and females (23.9%) had a 70% higher rate of depression compared to males (14.1%) in 2017-2019.
Mental health challenges were more prevalent among some racial and ethnic groups. For example, the rate of depression was 3 times higher for multiracial (27.1%) and American Indian/Alaska Native adults (24.6%) and 2.5 times higher for white adults (21.1%) than Asian/Pacific Islander adults (8.6%). Despite performing better than other groups, Asian/Pacific Islander adults experienced the highest increase (23%) in the rate of depression from 7.0% in 2011-2013 to 8.6% in 2017-2019.
Chronic Disease. Disparities in rates of chronic disease — asthma, cancer, cardiovascular disease and diabetes — have remained wide and persistent over the years, with rates of multiple chronic conditions rising for many subpopulation groups prior to the COVID-19 pandemic. Between 2011-2013 and 2017-2019, rates of multiple chronic conditions increased for many populations: 15% for adults with some college or a college degree, 14% for white adults, 10% for Black and female adults and 9% for American Indian/Alaska Native adults.
Notable disparities in the prevalence of chronic disease persisted by race and ethnicity. In 2017-2019, the percentage of adults with multiple chronic conditions was 6 times higher for American Indian/Alaska Native adults (18.4%), 4 times higher for multiracial adults (14.1%) and 3 times higher for Black adults (10.7%) than for Asian/Pacific Islander adults (3.2%).
Disparities in Maternal Mortality and Food Insecurity Worsened in Recent Years.
Maternal Mortality. The report demonstrated persistent and growing disparities in maternal mortality. In 2015-2019, Black mothers (43.8 deaths per 100,000 live births) had a maternal mortality rate that was 3.4 times higher than Hispanic mothers (12.7 deaths per 100,000 live births). Between 2005-2009 and 2015-2019, maternal mortality rates increased 22% among Black mothers, from 35.8 to 43.8 deaths per 100,000 live births. The maternal mortality rate also increased 55% for white mothers (from 11.2 to 17.3 deaths per 100,000 live births) and 23% for Hispanic mothers (from 10.3 to 12.7 deaths per 100,000 live births) during this time period.
Food Insecurity. Even prior to the COVID-19 pandemic, disparities in household food insecurity — percentage of households unable to provide adequate food for one or more household members due to lack of resources — were wide, with gaps further widening between 2003-2007 and 2015-2019 as some subpopulation groups experienced a significant increase in food insecurity rates. During this time period, food insecurity rates increased 39% for American Indian/Alaska Native households (from 19.2% to 26.7%) — a 5 times higher rate of food insecurity than Asian/Pacific Islander (5.6%) households.
Disparities in food insecurity were also significant by education. In 2015-2019, households headed by an adult without a high school education (24.8%) had nearly a 6 times higher rate of food insecurity than households headed by college graduates (4.4%). Since the 2003-2007 time period, food insecurity rates increased 15% in households headed by those with less than a high school education, and 19% in households headed by college graduates.
Broad Disparities Across Populations Highlight Connection Between Education and Health
The report documented a strong link between educational attainment and health, demonstrated across several measures where adults who have attained higher levels of education have better health. Notably, adults lacking a high school education face the greatest social, economic and health challenges across the nation. For example, households headed by individuals with less than a high school education had a poverty rate of 30.7%, which was 6 times higher than households headed by college graduates (5.2%). Further, even prior to the COVID-19 pandemic, more than 1 in 4 households headed by adults with less than a high school education faced food insecurity.
The report found those with less than a high school education face substantial barriers to health care access as well. Compared to college graduates, the uninsured rate for individuals with less than a high school education is nearly 3 times higher (10.9% vs. 3.9%). The rate of avoiding care due to cost was also 3 times higher for those with less than a high school education when compared with college graduates (22.1% vs. 7.9%).
Key health outcomes were also correlated with educational attainment; those with less than a high school education faced poorer health outcomes. Compared to college graduates, adults with less than a high school education faced a rate of multiple chronic conditions nearly 3 times higher (16.2% vs. 5.7%). Adults with less than a high school education (25.4%) had a rate of reporting high health status almost 3 times lower than college graduate adults (65.2%).
Addressing Health Disparities to Promote Health Equity in Our Communities
Achieving the highest level of health for all people will require communities, states and the nation to understand and identify how disparities impact the health of everyone. Race and ethnicity, gender, geography educational attainment and income level should not decide one’s access to health care, or the determinants and outcomes that contribute to our holistic well-being.
The United Health Foundation invites national, state and community leaders, policymakers, advocates and others to use the data in the inaugural America’s Health Rankings Health Disparities Report to identify and address the breadth, depth and persistence of disparities affecting the health and well-being of Americans in states and communities across the U.S. These new data provide critical direction for closing longstanding gaps and building a stronger, more equitable America where all individuals have the opportunity to thrive.