America’s Health Rankings® has become established as the nation’s annual checkup. However, in the late 1980s, there was serious skepticism that a health-based, data-driven ranking of the 50 states was doable. There seemed to be an overwhelmingly wide variety of sometimes narrowly defined, disease- and death-related factors that provided varied-but-limited definitions of health.
“Back then there were lots of discussions about if the project was even possible—with some saying it was not,” recalls Tom Eckstein, who led the team creating that first report. “There were two concerns: 1) How can you combine such disparate measures and end up with anything that is meaningful, and 2) Will the co-linearity of the measures overwhelm any other information provided by some of the measures?”
There were no lofty discussions about this project becoming the longest-running assessment of the nation’s health and a report that would annually raise up for public scrutiny the health of each state and the country. “As for the future, I didn't have any expectations,” says Eckstein. “And I had to dismiss the doubters. I signed a contract and had a project to do. It was not an option to not do something.”

Tom Eckstein

America’s Health Rankings® was created to show how health varies among the states. It was also created “to move the discussion toward a holistic notion of health and wellness,” says Eckstein, “and away from the historical mortality/morbidity-focused discussion. Also, we wanted to meld the multiple discussions about how to measure health into a unified measure.”
The report’s results sometimes raise eyebrows and often cause conversations to begin or renew. Individuals, elected officials, health care professionals, public health professionals, employers, educators, and communities analyze and react to America’s Health Rankings® with the same question: “How can we improve our population’s health?”
The second report, which became the benchmark, was released in 1990 when the definition of health and the role of public health were rapidly evolving. It was 26 years after the landmark 1964 Surgeon General Report on Smoking and Health as well as 8 years before the Tobacco Master Settlement Agreement between attorneys general of 46 states and 4 of the largest tobacco companies. In this period, research supporting the connection between population health and socioeconomic factors expanded, entered mainstream discussion, and became increasingly accepted.

Jonathan Fielding, MD

Twenty-five years ago, this expanding area of research and a distinguished expert panel fed the wellspring of what was to become a national benchmark in assessing health. “We had the beginnings of America’s Health Rankings®,” says Jonathan Fielding, MD, professor of Health Policy and Management, and Pediatrics, and member of the Delphi Panel that designed the model and selected metrics for the initial report. “This has been an important contribution to how we think about health and what we can do to improve health in our great nation.”
Here is a timeline of major events in the history of America’s Health Rankings®.
1989—The pilot report is released in October using 16 measures to produce the state rankings. It is a team effort between Northwestern National Life Insurance Company and T E Eckstein & Associates in Saint Paul, Minnesota, to present health in accordance with the World Health Organization definition: “Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” The 50 states were ranked, but feedback from individual states called for improvements in methodology and content, which led to major revisions within the report.
1990—First benchmark edition of The NWNL State Health Rankings: Results, Methodology, and Discussion is released. “There was a substantial reworking of the model between 1989 and 1990,” recalls Eckstein. “From a public relations point of view, 1989 may have been a success, but the model lacked the breadth and depth states desired and required additional buy-in to the methodology and the process of ranking. Hence, 1990 is the start date of the 25 years using a comparable model. Starting in the early 1990s, we did year-to-year comparisons based upon 1990.” A 12-member Delphi Panel selected from health and government professions created the report using 17 “components” grouped by lifestyle, access, disability, disease, and mortality. Top 5 states: 1) Utah 1) Minnesota 3) New Hampshire 4) Hawaii 5) Nebraska and Connecticut. Bottom 5 states: 50) Alaska 49) West Virginia 47) Mississippi 47) Nevada 45) Louisiana and New Mexico.
1991—Two sets of results are published. One is used to compare with the 1990 edition, and a “1991 with Environment Included” edition broadened the definition of health to include environmental issues. This is based on a second Delphi Panel wanting to explore how to better include environmental factors in the findings. Lack of solid measurement components at this time led to discontinuation of the “Environment Included” edition. Direct comparisons between the 1990 edition and the 1991 “Environment Included” edition were “not possible because of differences in data and weighting.” Top 5 states: 1) Hawaii 2) Minnesota 3) New Hampshire and Utah 5) Wisconsin and Nebraska. Bottom 5 states: 50) West Virginia 49) Alaska 47) New Mexico and Mississippi 46) Louisiana. Top 5 states “Environment Included”: 1) Hawaii 2) Nebraska 3) Minnesota and New Hampshire 5) Wisconsin and Vermont. Bottom 5 states “Environment Included”: 50) Alaska 49) Louisiana 48) Mississippi 46) Arizona and West Virginia.
1994—Report includes a summary of changes in the nation’s health. “Overall, the health of people in the United States has improved 2.4% since 1990. This indication of improved health was primarily due to a drop in prevalence of smoking, fewer deaths attributed to motor vehicles, great support for public health care for lower income people, and reduced infant mortality.” Top 5 states: 1) New Hampshire 2) Minnesota 3) Utah and Connecticut 5) Hawaii. Bottom 5 states: 50) Louisiana 49) Mississippi 48) West Virginia 46) South Carolina and Arkansas.

Rick Naymark

1995—Report’s name changes to The ReliaStar State Health Rankings, reflecting the new name of Northwestern National Life Insurance Company’s parent company, ReliaStar Financial Corp. The name change has no effect on the product. “It was amazing how readily the report’s information was accepted and validated by the public and by health experts,” recalls Rick Naymark, former Assistant Vice President of advertising and public relations at ReliaStar. “They said, ‘This makes sense!’ In just a couple of years, the report became the basis by which states would use criteria to establish goals to improve health.” Top 5 states: 1) New Hampshire 2) Minnesota and Utah 4) Connecticut and Hawaii. Bottom 5 states: 50) Mississippi 49) Louisiana 48) South Carolina 47) West Virginia 45) Arkansas and Nevada.
1997—Report cites the Government Accounting Office’s (GAO) recognition of The ReliaStar State Health Rankings as a “leading composite indicator of health.” The GAO says the “ReliaStar state health status index is an overall measure by state of the general health of the population in the United States. The index was first published in October 1989 and has been published annually ever since. Except for one major refinement in 1990, the methodology used to produce the index has generally remained the same. Therefore, versions of the index since 1990 are essentially comparable and can be used to note shifts in measured heath status from year to year.” This is the final year of T E Eckstein & Associates; in 1998 the research firm becomes Arundel Street Consulting, Inc. Top 5 states: 1) Minnesota 2) New Hampshire 3) Hawaii and Massachusetts 5) Wisconsin. Bottom 5 states: 49) Mississippi and Louisiana 48) New Mexico 47) Nevada 45) West Virginia and Arkansas.
1999Report’s name is changed to UnitedHealth Group State Health Rankings. ReliaStar Financial Corp. sells its health insurance interests to focus on life and disability insurance as well as financial services. “We approached UnitedHealth Group, and they liked the product,” says Rick Naymark, formerly with ReliaStar. “With the release of each annual report, I was on the radio for days discussing the findings. It was sent to all state health commissioners, and it was used extensively in sales development. The transition to UnitedHealth Group went smoothly because that report had become a benchmark in public health.” Top 5 states: 1) Minnesota 2) New Hampshire 3) Massachusetts 4) Wisconsin 5) Vermont. Bottom 5 states: 50) Arkansas 49) Mississippi 48) Louisiana 47) South Carolina 46) Nevada.

Georges Benjamin, MD

2000—The Rankings is published in partnership with the American Public Health Association (APHA) and Partnership for Prevention. The report “has captured the health of Americans in such a way that we’ve been able to do something about it,” says Georges Benjamin, M.D., APHA’s Executive Director. This is the result of the new leadership of Reed Tuckson, MD, FACP, former Vice President and Chief of Medical A—ffairs at UnitedHealth Group. “We wanted to draw on the considerable expertise and dissemination capabilities of the APHA and Partnership for Prevention,” says Tuckson. “We sought to become embedded in the flag of those unimpeachable organizations. They embraced us eagerly, and we gained credibility.” Data-driven results in the report find that overall health of the US "population has improved 17.3% since 1990, up 2.6% from the 1999 rankings. This change is due to a 6.8% decrease nationally in the prevalence of smoking, a 40% decrease in motor vehicle deaths, a dramatically lower rate of unemployment, a 7.3% increase in prenatal care, a near tripling in support for public health care, a reduction in heart disease, a 30% reduction in infant mortality and fewer premature deaths.” Top 5 states: 1) New Hampshire 2) Minnesota 3) Utah 4) Massachusetts 5) Hawaii. Bottom 5 states: 50) Mississippi 49) Louisiana 48) South Carolina 47) West Virginia 46) Arkansas.
2002—Dr. Tuckson, formerly Health Commissioner for Washington, DC, is the driving force in creating the report’s Scientific Advisory Committee. He pushes the initiative to make the Rankings more than a measurement tool but a call for action. Report is now titled America’s Health: UnitedHealth Foundation State Health Rankings: A Call to Action for People and Their Communities. (In 2003, the title would change again to America’s Health: State Health Rankings: A Call to Action for People & Their Communities.) Health disparities are covered for the first time in the Findings. Top 5 states: 1) New Hampshire 2) Minnesota 3) Massachusetts 4) Utah 5) Connecticut. Bottom 5 states: 50) Louisiana 49) Mississippi 48) South Carolina 47) Arkansas 46) Oklahoma.

2004—Dr. Tuckson is called by John Breaux, US Senator from Louisiana. “He said, ‘I saw your report and I want to see you in my office,’” recalls Tuckson. “He was upset, and I was scared. I was afraid he was going to say things like, ‘Your report is making my state look bad.’ Instead, I flew down there four times to be part of a fantastic statewide action council of top political figures including Gov. Kathleen Blanco. We did great planning to improve the health of Louisiana—and then Hurricane Katrina hit.” Appearing in the report for the first time is a comparison of individual measures in the United States with the same measures of other nations. “Today, 28 countries have healthy life expectancies that exceed the United States….” Top 5 states: 1) Minnesota 2) New Hampshire 3) Vermont 4) Hawaii 5) Utah. Bottom 5 states: 50) Louisiana 49) Mississippi 48) Tennessee 47) South Carolina 46) Arkansas.
2005—Report is now titled America’s Health Rankings®: A Call to Action for People and Their Communities. “Overall, the health of the United States’ population has improved 18.4% since 1990, up by 0.9% from the 2004 Edition. As Graph 1 shows, the rate of improvement in the health of the United States’ population has slowed in the past six years. During the 1990s, health improved at an average annual rate of 1.5% per year. Since 2000, the annual rate of improvement has slipped to an average of 0.3% per year.” Top 5 states: 1) Minnesota 2) Vermont 3) New Hampshire 4) Utah 5) Hawaii. Bottom 5 states: 50) Mississippi 49) Louisiana 48) Tennessee 47) Arkansas 46) South Carolina.
2008—Reflecting the complexities of assessing state health and the ongoing evolution of America’s Health Rankings®, the number of measures has steadily grown from 17 in 1990 to 22 with this report. Top 5 states: 1) Vermont 2) Hawaii 3) New Hampshire 4) Minnesota 5) Utah. Bottom 5 states: 50) Louisiana 49) Mississippi 48) South Carolina 47) Tennessee 46) Texas.
2009—For the first time 15 supplemental measures (eg, cholesterol check and dental visit) appear in the 20th edition of America’s Health Rankings®. “The core measures used in the Rankings are a small fraction of those measures available to the public and public health officials.” These are the “additional measures that are useful in understanding the health of your state and provide information for more in-depth analysis.” Top 5 states: 1) Vermont 2) Utah 3) Massachusetts 4) Hawaii 5) New Hampshire. Bottom 5 states: 50) Mississippi 49) Oklahoma 48) Alabama 47) Louisiana 46) South Carolina.

Sarah Milder, MPH, presents abstract at the Council of State and Territorial Epidemiologists Annual Conference.

2011—Sarah Milder, MPH, joins Arundel Street Consulting, Inc, as an epidemiologist. In 2015, Milder and Tom Eckstein will become principals of a new firm, Arundel Metrics, Inc, that specializes in data analysis. BRFSS changes its method of analysis this year, which affects the report going forward. A process called raking is adopted in order to better include more diverse segments of the population and improve the accuracy of survey estimates. Also, BRFSS begins to survey households using a cell phone as the primary residential phone and do not have a landline. This allows surveyors to reach a larger proportion of the population, particularly adults aged 25 to 34 and those living with only unrelated roommates, renting their home, and living in poverty. Because of these BRFSS changes, certain measures (eg, smoking, obesity, physical inactivity) from the 2012 edition onward cannot be directly compared with estimates from previous years, and the report for the first time is prevented from making evaluations about the overall health of the nation getting better or worse. Top 5 states: 1) Vermont 2) New Hampshire 3) Connecticut 4) Hawaii 5) Massachusetts. Bottom 5 states: 50) Mississippi 49) Louisiana 48) Oklahoma 47) Arkansas 46) Alabama.
2013—Launch of America’s Health Rankings® Senior Report. “Americans are now living longer but with increased rates of preventable chronic disease among the general population. As a result of this finding—and recognizing the growing number of seniors in the United States—we believe it is time to invest in a report that takes an in-depth look at senior health… If our nation’s seniors are unhealthy, can we be healthy as a society?” Top 5 states Senior Report: 1) Minnesota 2) Vermont 3) New Hampshire 4) Massachusetts 5) Iowa. Bottom 5 states Senior Report: 50) Mississippi 49) Oklahoma 48) Louisiana 47) West Virginia 46) Arkansas.
2014—The 25th anniversary edition of the report is released and includes an analysis of 25 years of changes in measures of mortality (premature death, infant mortality, cardiovascular deaths, cancer deaths, children in poverty), smoking, obesity, high school graduation, violent crime, and clinical care. 

Ralph Alswang

In this video, Dr. Tuckson is passionate about the progress and future of America’s Health Rankings. He says: “I am excited by the fact that now we are having this public conversation with America—and that we’re good at it and that the nation is starting to pay attention.  We’re getting together as individuals, members of families, and communities. We’re beginning to talk much more about how we can collectively address these preventable problems that will not only define the health of individuals and the health of the nation but will also be able to tell us whether we will be able to ever afford the medical care costs that are threatening the very viability of the nation’s economy.” Looking back and looking ahead, the 25th anniversary edition of the report summarizes: “Over the last 25 years, we have seen significant declines in premature death, infant mortality, cancer and cardiovascular deaths, as well as declines in smoking. While we celebrate the nation’s significant health gains made over the past 25 years, we also don’t want to lose sight of the sobering challenges we face. If we want to be a healthier place 25 years from now, we must all be in this together.”

Sarah Milder, MPH, and Tom Eckstein, foreground at the 25th anniversary of America's Health Rankings®. Behind them, left to right, are press conference panelists Anna Schenck, PhD, MSPH, Georges Benjamin, MD, and Reed Tuckson, MD.

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