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Before the COVID-19 pandemic, wide and persistent disparities existed across measures of overall health, chronic disease, mental and behavioral health and mortality. At the same time, promising progress was made across the nation in reducing disparities in infant mortality rates.
High Health Status
High health status is defined as the percentage of adults who self-report their health as very good or excellent. High health status is a strong predictor of overall health, well-being and mortality.1
Disparities persisted in high health status, particularly by educational attainment. In 2017-2019, adults with less than a high school education (25.4%) had an almost three times lower rate of reporting high health status than college graduate adults (65.2%). In addition, between 2011-2013 and 2017-2019, rates of high health status declined 4% among high school graduates, 7% among those with some college and 4% among college graduates.
In 2017-2019, Asian/Pacific Islander (54.3%) and white (53.4%) adults had 43% and 41% higher rates, respectively, of self-reporting high health status than Hispanic (37.9%) adults. Between 2011-2013 and 2017-2019, white adults were the only racial and ethnic group to experience a decline in high health status: 3% from 55.3% to 53.4%.
The inaugural America’s Health Rankings Health Disparities Report includes four individual measures of chronic disease—asthma, cancer, cardiovascular disease and diabetes—along with a combined measure referred to as multiple chronic conditions. Multiple chronic conditions measure the percentage of adults who report being told by a health care provider that they have three or more of the following chronic health conditions: arthritis, asthma, chronic kidney disease, chronic obstructive pulmonary disease, cardiovascular disease, cancer, depression and diabetes.
Multiple chronic conditions, cardiovascular disease and other conditions have been identified by the Centers for Disease Control and Prevention (CDC) as risk factors for severe COVID-19 illness and hospitalization. Emerging studies show that nearly two-thirds of COVID-19 related hospitalizations among U.S. adults were attributable to preexisting cardiometabolic conditions such as obesity, diabetes and cardiovascular disease.
Disparities in rates of chronic disease 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 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—all of whom experienced the greatest increases.
By 2017-2019, adults with less than a high school education had a three times higher rate of multiple chronic conditions (16.2% vs. 5.7%) and a two times higher rate of cardiovascular disease (13.6% vs. 5.6%) and diabetes (17.7% vs. 7.3%) than college graduate adults. Females had higher rates of asthma (11.5% vs. 6.4%), cancer (8.1% vs. 5.5%) and multiple chronic conditions (12.1% vs. 7.9%) than males.
Notable disparities in chronic disease prevalence persisted by race and ethnicity. In 2017-2019, American Indian/Alaska Native, multiracial and Black adults had significantly higher rates of multiple chronic conditions, asthma, cardiovascular disease and cancer than Asian/Pacific Islander populations.
There was also considerable variation in rates of multiple chronic conditions by subpopulation groups across states. Arkansas, Indiana, West Virginia, Rhode Island and Nebraska had the highest racial and ethnic disparities in rates of multiple chronic conditions in 2017-2019, whereas Hawaii, Montana, South Dakota, Alaska and Wisconsin had the lowest disparities. Across 38 states, American Indian/Alaska Native adults had the highest rates of multiple chronic conditions, ranging from a high of 37.6% in West Virginia, and a low of 11.2% in Utah.
Behavioral and Mental Health
This report includes three measures of behavioral and mental health—depression, frequent mental distress and excessive drinking. Mental health conditions, such as depression and anxiety, affect a person’s thoughts, feelings, moods and behaviors, and often co-occur with substance use disorders. Wide disparities exist in behavioral and mental health by education, gender, and race and ethnicity, with worsening rates for many subpopulation groups.
In 2017-2019, adults with less than a high school education had a 123% higher rate of frequent mental distress (17.6% vs. 7.9%) and 46% higher rate of depression (22.0% vs. 15.1%) than college graduate adults. On the other hand, excessive drinking was highest among those with some college (19.5%) or a college degree (19.2%).
Females had a 70% higher rate of depression (23.9% vs. 14.1%) and 38% higher rate of frequent mental distress (14.3% vs. 10.4%) than males. However, males (23.3%) had a 66% higher rate of excessive drinking than females (14.0%).
Racial gaps were also wide in behavioral and mental health. Multiracial, American Indian/ Alaska Native and white adults had significantly higher rates of depression, frequent mental distress and excessive drinking than Asian/Pacific Islander adults.
In 2017-2019, the racial gap in depression varied widely across states, with New Hampshire, Massachusetts, North Dakota, Missouri and Michigan having the highest disparities, and Wisconsin, South Dakota, Wyoming, Kentucky and, Montana having the lowest disparities.
Between 2011-2013 and 2017-2019, rates of depression and frequent mental distress increased significantly for female and white adults, as well as for adults with a high school education, some college and college graduates. During this period, 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.
Maternal and Infant Health
Three measures of maternal and infant health are included in this report: low birthweight, infant mortality and maternal mortality. The well-being of infants and mothers is central to shaping the health of future generations. Yet, the U.S. ranks toward the bottom internationally among high income countries on rates of infant and maternal health and mortality.2, 3 Factors driving these poor outcomes and disparities are complex and multifactorial, including health insurance coverage, access to care and broader social, economic and structural inequities.4, 5
Maternal Mortality. Maternal mortality is measured as the number of maternal deaths per 100,000 live births. In 2015-2019, the national maternal mortality rate was 19.9 per 100,000 live births. Since 2005-2009, the racial gap in maternal mortality rates has widened, with Black mothers facing both a disproportionately higher rate of mortality and increasing rates over time.
In 2015-2019, Black mothers (43.8) had a maternal mortality rate that was 3.4 times higher than Hispanic mothers (12.7), who had the lowest rate in the nation. Between 2005-2009 and 2015-2019, maternal mortality rates increased 22% for Black mothers from 35.8 to 43.8 deaths per 100,000 live births. During this period, white mothers had a 55% increase from 11.2 to 17.3 deaths per 100,000 live births, and Hispanic mothers had a 23% increase from 10.3 to 12.7 deaths per 100,000 live births.
In 2015-2019, American Indian/Alaska Native (33.9) mothers also had a high rate of maternal mortality—2.7 times higher than Hispanic mothers (12.7)—with rates staying persistently high over time. Furthermore, mothers in non-metropolitan areas (27.6%) had a 1.5 times higher rate of maternal mortality than mothers in metropolitan areas (18.8%), with no improvements since at least 2010-2014.
Infant Mortality. The Infant mortality rate is defined as the number of deaths (before age 1) per 1,000 live births. In 2015-2018, the national infant mortality rate was 5.8 per 1,000 live births—a rate that was 5th highest globally among other high-income countries.
Over the last 16 years , the nation has made progress in reducing the racial gap in infant mortality. The infant mortality rate declined by 19% for Black, 16% for white, 13% for Asian/Pacific Islander and 11% for Hispanic infants between 2003-2006 to 2015-2018. However, no progress was made in reducing the high infant mortality rate among American Indian/Alaska Native infants (8.6)—who continued to have a rate that was two times higher than Asian/Pacific Islander infants (4.0) with the lowest rate.
Similar to outcomes on maternal health, Black infants (11.0) had the highest infant mortality rate—which was 2.8 times higher than Asian/Pacific Islander infants (4.0)—in 2015-2018. However, promising progress was made between 2003-2006 and 2015-2018 as 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. While these states have made great strides, continued progress is needed to close wide gaps in infant mortality rates.
Premature death is defined as the number of years of potential life lost before age 75 per 100,000 population. A combination of conditions such as cancer, unintentional injury, heart disease, suicide, perinatal deaths and homicide contribute to years of potential life lost before age 75. The Centers for Disease Control and Prevention (CDC) estimate that 20-40% of premature deaths are preventable.
Racial disparities in premature death are striking. In 2015-2019, American Indian/Alaska Native (11,383) and Black (10,582) populations had the highest number of years of lost life per 100,000—a rate three times higher than the Asian/Pacific Islander (3,195) population, who had the lowest rate. The white (7,796) population also had a two times higher rate of premature death than the Asian/Pacific Islander population.
Between 2005-2009 and 2015-2019, the rate of premature death increased for the American Indian/Alaska Native population by 15% and for the white population by 5%. At the same time, some progress was made to reduce premature death among the Black and Hispanic populations who each experienced a 6% decline.
The American Indian/Alaska Native population faced the highest rates of premature death in the top 10 states with the highest racial disparities in 2015-2019. In South Dakota—the state with the highest racial disparities—the American Indian/Alaska Native population who had the highest rate had a 3.5 times higher rate of years of potential life lost than the Hispanic population who had the lowest rate (22,598 vs. 4,291 years of life lost before age 75 per 100,000). The racial gap was even wider when comparing premature death across states.
 Kuhn, R., et al. (2006). Survey Measures of Health: How Well Do Self-Reported and Observed Indicators Measure Health and Predict Mortality? In: National Research Council (US) Committee on Population; Cohen B, Menken J, editors. Aging in Sub-Saharan Africa: Recommendation for Furthering Research. Washington (DC): National Academies Press (US). Available from: https://www.ncbi.nlm.nih.gov/books/NBK20307/
 Jacob, J. (2016). US Infant Mortality Rate Declines but Still Exceeds Other Developed Countries. JAMA, 315(5):451-452. doi:10.1001/jama.2015.18886
 GBD 2015 Maternal Mortality Collaborators. (2016 October). Global, regional, and national levels of maternal mortality, 1990-2015: systematic analysis for Global Burden of Disease Study 2015. The Lancet, 388(10053): P1775-1812. https://doi.org/10.1016/S0140-6736(16)31470-2
 Artiga, S., et al. (2020 November 10). Racial Disparities in Maternal and Infant Health: An Overview. Kaiser Family Foundation. https://www.kff.org/report-section/racial-disparities-in-maternal-and-infant-health-an-overview-issue-brief/
 Crear-Perry, J., et al. (2021 February). Social and Structural Determinants of Health Inequities in Maternal Health. Journal of Women’s Health, 30(2). https://doi.org/10.1089/jwh.2020.8882