2016 - America's Health Rankings
A call to action for individuals and their communities2016
FindingsBehaviorsCommunity a’s Health Rankings was built upon the World HealthOrganization definition of health:“Health is a state of complete physical, mental, and social wellbeing and not merely the absence of disease or infirmity.”The model reflects that determinants of health directly influencehealth outcomes. A health outcomes category and four categoriesof health determinants are included in the model: behaviors,community & environment, policy, and clinical care.Bww w. a m e r i c a s h e a l t h ra n kin g s.o r g
ContentsExecutive Summary2Introduction4Findings5Overview5State Rankings5Largest Changes in Rank Since 20158Determinants and Outcomes9National Findings11National Successes11National Challenges12Smoking and Obesity: A Public Health Success and Challenge13Trends in Smoking Prevalence, 2012 to 201614Trends in Obesity Prevalence, 2012 to 201618Annual Rate of Change in Smoking and Obesity22Comparison With Other NationsCore Measures2327Behaviors28Community & Environment40Policy48Clinical Care56Outcomes60Supplemental Measures75State Summaries89US Summary142Appendix145Core Measures Table146Supplemental Measures Table148Methodology150Model Development152Scientific Advisory Committee154The Team155AMER IC A’ S H EA LTH R A N K IN GS AN N UA L R E P ORT1
America’s Health Rankings Annual ReportExecutive SummaryOverviewFor 27 years, America’s Health Rankings AnnualReport has served as the nation’s source for trendsin nationwide public health and state-by-staterankings. The report analyzes a comprehensive setof behaviors, community and environment, policy,clinical care, and outcomes data to provide a holisticview of the health of the nation. It also offers abenchmark to compare each state’s progress anddeclines over the past 27 years against nationalperformance, offering insights into the success ofpublic health efforts. All information is available in asingle, easy-to-use web platform that allows users toexplore health measures and state data for customcomparisons.In the 2016 edition, the report looks at historicaltrends and finds that the health of the nation is ata critical crossroad between making encouragingprogress against long-standing public healthchallenges, while treading into dangerous territoryon other key health indicators. For instance, thenation has experienced successes in reducing theprevalence of smoking, the number of preventablehospitalizations, and the percentage of thepopulation without health insurance. However,the nation faces health concerns with drug andcardiovascular deaths and a continued highprevalence of obesity.With these observations, the United HealthFoundation continues its commitment to providingvaluable information to policymakers, public healthofficials, and communities with the goal of stimulatinga dialogue on strategies to improve the health ofour communities. The longevity of the report andwealth of credible data from trusted sources providea unique opportunity for America’s Health Rankingsto track both short-term successes and challenges,and identify emerging areas of interest that indicateimprovement or decline since 1990.2ww w. a m e r i c a s h e a l t h ra n kin g s.o r gNation Continues to Experience Declines inPrevalence of Smoking, Rate of PreventableHospitalizations, and Percentage of thePopulation Who Are UninsuredHighlighting key national successes, the reportfinds that the United States has made notablelong-term improvements across key indicatorsof health, including smoking, preventablehospitalizations, and health insurance coverage. Since 1990, the prevalence of smoking in theUnited States has decreased 41%, includinga 17% decline over the past four years. During the last decade, the rate ofpreventable hospitalizations among Medicareenrollees has declined 35% and declined13% in the past year alone. The percentage of the population that isuninsured declined 35% over the past fiveyears and is now at the lowest point in theAnnual Report’s 27-year history.Rising Rates of Cardiovascular and DrugDeaths and High Prevalence of ObesityPresent National Health ChallengesAs the nation celebrates encouraging progresson key indicators of health, the report alsohighlights serious challenges for the country thatare eroding hard-won health gains. This year,the rates of cardiovascular and drug deathsincreased nationally and the prevalence ofobesity remained high. This year marks the end of a 26-year declinein the rate of cardiovascular deaths. In thepast year, the national cardiovascular deathrate increased from 250.8 to 251.7 deathsper 100,000.
The United States has made notable long-term improvementsacross key indicators of health, including smoking, preventablehospitalizations, and health insurance coverage. The report also finds that in the past five years,the rate of drug deaths has increased 9%, rising4% in the past year alone.This year, the rates of cardiovascular anddrug deaths increased nationally and theprevalence of obesity remained high. Premature death, the years of potential lifelost before age 75, increased for the secondconsecutive year. Since the start of America’s Health RankingsAnnual Report in 1990, the prevalence of obesityamong adults has increased 157%.2016 Ranking of the Healthiest Overall StatesThe report ranks each state across 34 measuresof behaviors, community and environment, policy,clinical care, and outcomes. This year, northeasternstates generally rank among the healthiest overallstates, while southeastern states generally rankamong those states with the greatest challenges.Hawaii ranks as the healthiest state for the fifthstraight year. The state has held the top spot eighttimes in the 27-year history of the Annual Report.Massachusetts (second), Connecticut (third),Minnesota (fourth), and Vermont (fifth) round out thetop five states for overall health.Informing Conversations About Improvingthe Health of Our NationWith this report, United Health Foundationcontributes 27 years worth of data to ongoingconversations among policymakers, publichealth officials, and community leadersabout how they can collaborate to promoteand achieve better health for all. Our nationhas experienced impressive public healthachievements since the launch of the firstAmerica’s Health Rankings Annual Reportin 1990, but this year’s findings highlight thatthe country still faces critical challenges thatmay undermine progress in other key areas ofhealth. Those working to improve the healthof our nation are encouraged to use the reportas a call to action for positive change in theircommunities.Mississippi ranks as the state with the greatestopportunity for improvement, dropping from49th to 50th this year. Louisiana improved to49th, while Arkansas (48th), Alabama (47th), andOklahoma (46th) round out the states with greatestopportunities for improvement.AMER IC A’ S H EA LTH R A N K IN GS AN N UA L R E P ORT3
IntroductionThe United Health Foundation is pleased to releasethe 2016 America’s Health Rankings AnnualReport. For 27 years, this report has provideddata-driven insights and measurements to improvehealth across the country on a state-by-state basis.America’s Health Rankings serves as an actionableresource for public health professionals, electedofficials, employers, individuals, and communities toidentify needs for improving our population’s health.America’s Health Rankings Annual Report servesthe United States and, in particular, public health by:1. Providing a benchmark for states. As thelongest-running annual assessment of America’shealth on a state-by-state basis, this report isvital for gauging how each state’s health changesfrom year to year and decade to decade, andhow each state compares with the health ofother states and the nation overall. The data formany measures extend back to 1990 and areinvaluable when forming a wide-angle, holisticview of state and US health. America’s HealthRankings Annual Report presents findings “fromthe front lines” of population health, revealingboth encouraging and troubling trends over time.2. Stimulating action. This is the overarchingpurpose of the report—to be a catalyst for datadriven discussions on indicators that have thepotential to improve health and drive positivechange. Numerous states incorporate the reportinto their annual review of programs, and manyorganizations use the report as a reference pointwhen assigning goals for health-improvementprograms.The 2016 edition of America’s Health RankingsAnnual Report highlights promising progress inprincipal markers of our nation’s health. Examples:Smoking prevalence, the rate of preventablehospitalizations, and the percentage of the4ww w. a m e r i c a s h e a l t h ra n kin g s.o r gpopulation without health insurance continue tofall. At the same time, problems are mixed in withprogress. Our nation continues to struggle withcertain stubborn health concerns—obesity anddrug deaths. Premature deaths increased for thesecond consecutive year and the long-term trendof declining cardiovascular deaths has ended. Twoof the most troubling health concerns, smokingand obesity, are examined in a special section ofthis year’s report. Smoking and Obesity: A PublicHealth Success and Challenge (pages 13–22),takes a deeper dive into five-year trends in smokingand obesity prevalence and illustrates how changesin these markers are not shared uniformly acrossstates and education levels.When reading the 2016 America’s HealthRankings Annual Report, it is important to readbeyond the “headlines” of the rankings. Everystate has strengths and challenges. Additionally,each measure does not stand alone but is astrand in the web of health and everyday life ofAmericans. Example: A change for the good inphysical inactivity could affect obesity, diabetes,cardiovascular deaths, and other measures.America’s Health Rankings new website,americashealthrankings.org, allows users to readand download the entire report and to study andanalyze the data by state or by measure of interest.A detailed view of this report is available in theLearn section, and the Explore section provides avariety of tools to visualize trends and variationsin rankings geographically and by demographiccharacteristics.America’s Health Rankings Annual Reportprovides a continually evolving snapshot ofhealth, yields important insights on how eachstate’s health changes over time, and—perhapsmost importantly—enables action for makingcommunities and states healthier.
FindingsOverviewThe 2016 America’s Health Rankings Annual Reportfinds: Hawaii—for the fifth consecutive year—is thehealthiest state. Iowa makes the biggest improvement in rank inone year, rising five spots from 22nd to 17th. Some states score much better in healthdeterminants than health outcomes, which mayhave implications for future population health. There are national improvements in preventablehospitalizations among Medicare enrollees,smoking prevalence, and public health funding.High school graduation continues a three-yearupward trend, and human papillomavirus (HPV)immunizations are increasing among male andfemale adolescents. Long-term improvements inhealth insurance coverage continue. A lack of decline in obesity prevalence andan increase in drug deaths remain ongoingchallenges for the nation. Troubling increases in cardiovascular deaths andpremature death are occurring. Cardiovasculardeaths increased for the first time in the 27-yearhistory of America’s Health Rankings.State RankingsHealthiest StatesHawaii takes the title of the healthiest state in 2016,followed by Massachusetts (second). Connecticut(third) rises three spots this year to re-enter the topfive. Minnesota (fourth) and Vermont (fifth) completethe top five (Tables 1 and 2, Figures 1 and 2).Hawaii has ranked first for five straight years andhas been in the top spot eight times since 1990, themost for any state in the history of America’s HealthRankings. It has been in the top six states since thefirst edition of America’s Health Rankings in 1990.Hawaii also scores far better than other top-fivestates (Figure 1). Hawaii’s strengths include alow prevalence of obesity, a low percentage ofpeople without health insurance, and a low rateof preventable hospitalizations. In addition, HPVimmunization among females aged 13 to 17 yearsincreased 38% from 38.0% to 52.4% in the pastyear. The prevalence of diabetes decreased 13%from 9.8% to 8.5% of the adult population.All states have challenges and areas forimprovement. Hawaii scores above the nationalaverage in the prevalence of excessive drinkingand incidence of Salmonella, and below thenational average for tetanus-diphtheria-acellularpertussis (Tdap) immunization among adolescentsaged 13 to 17 years. These same challenges wereidentified in the 2015 America’s Health RankingsAnnual Report.Most Challenged StatesMississippi ranks 50th in 2016. Other states in thebottom five are Louisiana (49th), Arkansas (48th),Alabama (47th), and Oklahoma (46th) (Tables 1and 2, Figures 1 and 2). West Virginia improvesfour spots this year to rise out of the bottomfive. Mississippi has ranked in the bottom threestates since the first edition of America’s HealthRankings in 1990. Mississippi and Louisiana scorefar worse than the other states in the bottom five(Figure 1).Mississippi’s challenges include a highprevalence of smoking and low birthweight, and ahigh percentage of children in poverty. Mississippiranks in the bottom 10 for 25 measures, includingranking in the bottom three for all measures ofclinical care.All states, no matter their overall ranking, haveareas of strength. Mississippi ranks well for a lowprevalence of excessive drinking and a low rate ofdrug deaths, as well as a small disparity in healthstatus by education. Mississippi does better thanthe national average for low incidence of pertussisand low rate of violent crime.AMER IC A’ S H EA LTH R A N K IN GS AN N UA L R E P ORT5
FindingsTABLE 1TABLE 22016 RankingRank2016 tNew HampshireWashingtonUtahNew JerseyColoradoNorth DakotaNebraskaNew YorkRhode OregonMaineMontanaSouth kaDelawareNorth CarolinaTexasMichiganNevadaFloridaMissouriNew MexicoIndianaOhioGeorgiaSouth CarolinaWest uisianaMississippiww w. a m e r i c a s h e a l t h ra n kin g s.o r g2016 Alphabetical RankingOverall 2128144224443385197432025StateOverall MontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth est -0.626-0.2080.5780.7090.2640.582-0.5950.2200.116* Weighted standard deviationrelative to US value
FIGURE 12016 Overall aVermontNew HampshireWashingtonUtahNew JerseyColoradoNorth DakotaNebraskaNew YorkRhode OregonMaineMontanaSouth DakotaWyomingIllinoisUnited StatesKansasPennsylvaniaArizonaAlaskaDelawareNorth CarolinaTexasMichiganNevadaFloridaMissouriNew MexicoIndianaOhioGeorgiaSouth CarolinaWest uisianaMississippi-0.5000.0000.5001.000* Weighted standarddeviation relative toUS valueAMER IC A’ S H EA LTH R A N K IN GS AN N UA L R E P ORT7
FindingsFIGURE 22016 Ranking1–1011–2021–3031–4041–50not rankedDCRIDELargest Changes in RankSince 2015Iowa is the most improved state, rising five spotsfrom 22nd in 2015 to 17th in 2016 (Table 3).The state’s rise is due to improvements in thepercentage of children aged 19 to 35 monthsand adolescents aged 13 to 17 years receivingrecommended immunizations, including a 32%increase in HPV immunization among adolescentfemales. There are also improvements in pertussisincidence and public health funding.Other states showing notable improvementthis past year include West Virginia, Wisconsin,Connecticut, and Nevada. Wisconsin and WestVirginia each rise four spots, and Connecticut andNevada each rise three.Maine has the largest decline in rank over thepast year, moving from 15th in 2015 to 22nd in2016. South Dakota’s rank falls five spots, andAlaska, Florida, and Vermont all fall three spots.8ww w. a m e r i c a s h e a l t h ra n kin g s.o r gTABLE 3Largest Changes in Rank Since 2015 Edition(One-Year Change)Rank Improved2015 Rank2016 RankChangeIowaWest 3554433Rank Declined2015 Rank2016 RankChangeMaineSouth -3-3
TABLE 4Determinants and Outcomes Scores,* 2016Determinants and OutcomesFor states to improve the health of theirpopulation, their efforts must focus onimproving determinants of health. If a statescores better on health determinants thanit does on health outcomes, it may improveits health in the future. Conversely, if a statescores better on health outcomes than it doeson health determinants, its health may decline.Table 4 presents each state’s score fordeterminants, outcomes, and the implicationsfor future health. If the difference betweenthe determinants and outcomes scores(determinants greater than outcomes) is inthe top 25% of all differences (75th percentileor above), the potential future effect on healthis deemed positive and the state’s futurehealth may improve. If there is little differencebetween the determinants and outcomesscores (difference in the second and thirdquartiles), the state’s future health is unlikely tochange much and is labeled as a neutral effect.If the difference between the scores (outcomesgreater than determinants) is in the bottom25% of all differences, the effect is negativeand the state’s future health may decline.Louisiana, Mississippi, New Mexico, Nevada,and Alaska all have determinants scoresthat are much lower than their outcomesscores (Table 4, Figures 3 and 4). In contrast,Vermont, Massachusetts, Connecticut,Rhode Island, and New Hampshire all havedeterminants scores that are much higher thantheir outcomes ssouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth est coreDifferencein ScoresPotentialFuture Effecton tralPositiveNeutralPositiveNeutralNeutralNeutral* Weighted standard deviation relative to US valueAMER IC A’ S H EA LTH R A N K IN GS AN N UA L R E P ORT9
FindingsFIGURE 32016 Determinants Ranking1–1011–2021–3031–4041–50not rankedDCRIDEFIGURE 42016 Outcomes Ranking1–1011–2021–3031–4041–50not rankedDCRIDE10w w w. a m e r i c a s h e a l th ra n kin g s.o r g
NATIONALNational FindingsNational SuccessesSMOKING Smoking decreased 3% from 18.1% to 17.5% ofUS adults in the past year. Virginia and Arizonahad a statistically significant decrease in smokingprevalence. In the past four years, smoking decreased 17%from 21.2% to 17.5% of the adult population.IMMUNIZATIONS Immunization coverage among children aged19 to 35 months increased 6% in the past threeyears from 68.4% to 72.2%. There is still roomfor improvement before reaching the Departmentof Health and Human Services Healthy People2020 target of 80% coverage. Among adolescents aged 13 to 17 years, 81.3%and 86.4% received meningococcal and Tdapimmunizations in the past year, respectively.However, HPV immunization coverage is muchlower than the other recommended adolescentimmunizations; only 41.9% and 28.1% of femalesand males, respectively, received HPVvaccinations. HPV immunization coverage is improving. HPVimmunization among males aged 13 to 17 yearsincreased 30% in the past year, from 21.6% to28.1%, though coverage among males still lagsfar behind HPV immunization among females. Inthe past two years, HPV immunization coverageamong females aged 13 to 17 years increased11% from 37.6% to 41.9%.SUCCESSESHEALTH INSURANCE COVERAGE:The percentage of people withouthealth insurance decreased 19% from13.1% to 10.6% of the population inthe past year. This is the lowest levelin the history of America’s HealthRankings.PREVENTABLE HOSPITALIZATIONS:In the past 10 years, preventablehospitalizations decreased 35% from77.0 to 49.9 discharges per 1,000Medicare enrollees.HEALTH INSURANCE COVERAGE The percentage of people without healthinsurance decreased 19% from 13.1% to 10.6% inthe past year. This is the lowest level in the historyof America’s Health Rankings. Compared with 2011, the percentage of peoplewithout health insurance decreased 35% from16.2% to 10.6% of the population.PREVENTABLE HOSPITALIZATIONS Preventable hospitalizations decreased 13%from 57.6 to 49.9 discharges per 1,000 Medicareenrollees in the past year. In the past 10 years, preventable hospitalizationsdecreased 35% from 77.0 to 49.9 discharges per1,000 Medicare enrollees.Smoking and Obesity: A PublicHealth Success and Challenge(pages 13–22) provides ananalysis of five-year trends insmoking and obesity, includingvariations by state andeducation level.ADDITIONAL SUCCESSES The percentage of students graduating from highschool increased 2% from 81.4% to 83.2% ofstudents in the past year, continuing a three-yearupward trend.A MER IC A’ S H EA LTH R A N K IN GS A N N UA L R E P ORT11
Findings Public health funding increased 9% from 86 to 94 per person over the past year.National ChallengesOBESITY The prevalence of obesity remains high at 29.8%of the adult population and has not declined inthe past year. The prevalence of obesity decreased in 25 statesin the past year—although none of the decreaseswere statistically significant. It’s too early todetermine if these are meaningful changes.Additional trend data are needed to determine ifobesity has peaked in these states. The prevalence of obesity increased significantlyin one state—Kansas-—in the past year. In the past four years, obesity prevalenceincreased 7% from 27.8% to 29.8% of adults. Compared with 1990, obesity is 157% moreprevalent among US adults. In 1990, 11.6% ofadults were obese, compared with 29.8% now. One contributing factor to the rise in obesityprevalence is a long-term stagnation in physicalinactivity. For the past 15 years, the prevalenceof physical inactivity among adults has hoveredaround 25%. Increasing physical activity may benecessary to curb current trends in obesity.DRUG DEATHS Drug deaths are becoming a greater concernfor state, local, and national officials, as well as251.7This year cardiovascular deathsincreased for the first time in America’sHealth Rankings history, from 250.8 to251.7 deaths per 100,000 population12w w w. a m e r i c a s h e a l th ra n kin g s.o r gthe communities they serve. The rate of drugdeaths increased 4% from 13.5 to 14.0 deathsper 100,000 population in the past year. Thiscontinues a troubling trend. In the past five years, drug deaths increased 9%from 12.9 to 14.0 deaths per 100,000 population.SOUNDING THE ALARM: A REVERSAL OFLONG-TERM TRENDS?The 27-year history of America’s Health Rankingscan be used to examine the progress the nation hasmade to improve population health. The rankingsalso highlight when the nation’s health may bemoving in the wrong direction. There are alarmingchanges in two measures that have been historicallytrending in a positive direction. It is important tocall attention to these changes so that progresspreviously made is not further eroded.Premature death has been largely decliningsince 1990. Between the 2005 and 2015 editions,the rate of premature death decreased from 7,564to 6,997 years lost before age 75 per 100,000population. However, in the past year, prematuredeath increased for the second consecutive year,from 6,997 to 7,054 years lost before age 75 per100,000 population. While the premature deathrate has increased a few times during the history ofAmerica’s Health Rankings, this recent increase isimportant to monitor.Reducing deaths from heart disease hasbeen a major objective of the clinical and publichealth communities over the past few decades.Between 1990 and 2015, cardiovascular deathshave decreased 38% from 405.1 deaths to 250.8deaths per 100,000 population. However, this yearcardiovascular deaths increased for the first timein America’s Health Rankings history, from 250.8to 251.7 deaths per 100,000 population. While thismay be a relatively small increase, it is statisticallysignificant and is the first time since 1990 thatan increase of any magnitude has occurred. It isimportant to watch for developing trends in keyhealth outcomes so that individuals, communities,and officials can act to stem any erosion of ourprogress in improving population health.
Smoking and Obesity: A PublicHealth Success and ChallengeAmerica’s Health Rankings has tracked theprevalence of smoking among US adults since thereport was first published in 1990. Obesity was alsoincluded in 1990, but was a part of a combinedmeasure called “risk for heart disease.” Obesitywas explicitly added to the model in the 2004edition. To better gauge where the United Statesis in its recent efforts to reduce the prevalence ofsmoking and obesity, a five-year trend analysis wasconducted using data from the Centers for DiseaseControl and Prevention’s (CDC) Behavioral RiskFactor Surveillance System (BRFSS). The analysishighlights the variation in prevalence and the annualrate of change1 for both of these significant publichealth challenges by state and education level2using data from editions 2012 through 2016.Obesity is the second-leading cause ofpreventable death, close behind smoking. Obesitycontributes to conditions such as heart disease,stroke, diabetes, and certain cancers.3 Smokingalso contributes to cancer, heart disease, stroke,and respiratory diseases. In addition, smokinghas adverse effects on reproductive health, and itimpacts treatment of other chronic diseases suchas diabetes. The CDC estimates that smokingand secondhand smoke cause more than 480,000deaths annually, or one in five deaths.4 Since thepublication of the first Surgeon General’s report onsmoking and health in 1964, more than 20 millionAmericans have died from smoking.5Smoking has been steadily declining in the1. Average rate of change per year was calculated as the slope of a leastsquares fitted line in prevalence over the five-year period.2. Education levels analyzed were less than high school graduate, high schoolgraduate or equivalent, some college, and college graduate.3. Adult Obesity Facts. https://www.cdc.gov/obesity/data/adult.html. AccessedOctober 26, 2016.4. Centers for Disease Control and Prevention Fact Sheet. Current cigarettesmoking among adults in the US. https://www.cdc.gov/tobacco/datastatistics/fact sheets/adult data/cig smoking/index.htm. Accessed October26, 2016.5. US Department of Health and Human Services. The Health Consequencesof Smoking—50 Years of Progress: A Report of the Surgeon General.Atlanta, GA: US Department of Health and Human Services, Centersfor Disease Control and Prevention, National Center for Chronic DiseasePrevention and Health Promotion, Office on Smoking and Health, 2014.6. Trends in higher education: Smoking rates by education level, 1940-2008.The College Board website. 8. Accessed October26, 2016.United States since the mid-1960s.6 Since then,states have adopted numerous policies to preventpeople—especially youth—from starting to smoke,help people quit smoking, and help reduce deathand disabili
Hawaii has ranked first for five straight years and has been in the top spot eight times since 1990, the most for any state in the history of America's Health Rankings. It has been in the top six states since the first edition of America's Health Rankings in 1990. Hawaii also scores far better than other top-five states (Figure 1).
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