America's health rankings findings: who takes the crown as healthiest state?

Short-term successes and challenges

The 2014 report boasts three key successes since the 2013 edition:

1. Decreased smoking prevalence – a decline of 3%, from 19.6% to 19.0% of adults who regularly smoke
2. Increased immunization coverage – an increase of 5%, from 64% to 67.1% of adolescents aged 13-17 years
3. Decreased infant mortality – a decrease of 4%, from 6.3% to 6.0% of deaths per 1,000 live births.

On the flipside, the four major challenges exposed in the report:

1. Increased infectious disease pertussis – an incidence increase of 154%, from 6.1 to 15.5 cases per 100,000 population
2. Increased obesity – an increase of 7% from 27.6% to 29.4% of adults
3. Increased drug deaths – an increase of 7%, from 12.2 to 13.0 deaths per 100,000 population
4. Increased physical inactivity – an increase of 3%, from 22.9% to 23.5% of adults who did not participate in physical activity in the last 30 days.

“We applaud hard-won advances in several key measures, including smoking prevalence, even as this year’s America’s Health Rankings is a solemn reminder that we have a lot more work ahead of us,” comments Dr. Reed Tuckson, senior medical adviser to United Health Foundation, adding:

“It is inevitable that increases in the rates of obesity and physical inactivity will result in more people suffering from significant chronic diseases that compromise the quality of their lives, adversely affect their families and are unaffordable for the nation.”

United Health Foundation are marking 25 years of America’s Health Rankings by introducing new online tools to inspire health advocacy across states and communities.

A “Change My Rank” online tool allows users to see how improving several key measures affect the state’s overall rank (for example, if a state reduced its prevalence of obesity by 5%, what would its overall rank be?).

Long-term successes and challenges

The 10 main successes emphasized in the report since 1990 focus on:

1. Smoking – since 1990, smoking decreased 36%, from 29.5% to 19.0% of adults who regularly smoke
2. High school graduation – at 81% of ninth graders graduating within 4 years, high school graduation is still a challenge. However, it is slowly trending upward from 71.7% in 2004
3. Violent crime – at 387 offenses per 100,000 population, violent crime is 37% lower than in 1990 and 49% lower than its peak in 1993
4. Air pollution – the average amount of fine particulates in the air continues to decline from 13.2 micrograms per cubic meter in 2003 to 9.9 micrograms per cubic meter in 2014
5. Preventable hospitalizations – preventable hospitalizations continue to decline. In 2001, there were 82.5 discharges per 1,000 Medicare beneficiaries; in 2014, there were 62.9 discharges per 1,000 Medicare beneficiaries
6. Occupational fatalities – occupational fatalities have declined in the last 8 years, from 5.3 deaths per 100,000 workers in 2007 to 3.8 deaths per 100,000 workers. This is the second consecutive year the rate is below 4 deaths per 100,000 workers
7. Infant mortality – since 1990, infant mortality decreased 41%, from 10.2 to 6.0 deaths per 1,000 live births, although most of that decline occurred between 1990 and 1999. Even though the infant mortality rate is the lowest in US history, it is double the rate of many developed countries. In addition, large racial and geographic disparities exist within the country
8. Premature death – since 1990, premature death declined 20%, from 8,716 to 6,976 years of potential life lost before age 75. Premature death, like several other metrics, has leveled off in the last decade compared with improvements made in the 1990s
9. Cancer deaths – cancer deaths declined 4%, from 197.5 deaths in 1990 to 189.9 deaths per 100,000 population
10. Cardiovascular deaths – since 1990, cardiovascular deaths declined 38%, from 405.1 to 251.4 deaths per 100,000 population. This continues a relatively constant improvement of 2-3% yearly.

In contrast, there are eight challenges that have remained unchanged or have deteriorated since 1990:

1. Obesity – since 1990, obesity has increased 153%, from 11.6% to 29.4% of adults
2. Physical inactivity – physical inactivity remains high – at 23.5% of adults – and has not changed appreciably for the last decade
3. Children in poverty – at 19.9% of children, the children in poverty measure is far above the 23-year low of 15.8% in the 2002 edition and near the 1990 level of 20.6%
4. Public health funding – state public health funding continues its slow decline over the past 4 years. Since 2011, it decreased from $95.01 to $90.00 in expenditures per person at the state level
5. Child immunization coverage – nationwide, comprehensive immunization coverage among children aged 19-35 months is only 70.4%. It increased marginally in the past year
6. Adolescent immunization coverage – nationwide, comprehensive immunization coverage among teens aged 13-17 years is only 67.1%. It increased marginally in the past year
7. Low birthweight – in the last 20 years, the prevalence of low birthweight infants has increased, from 7.1% to 8.0% nationwide. The good news is that it appears to have peaked in 2009 and is trending downward
8. Diabetes – in the nation, 9.6% of adults report they have been told they have diabetes. There has been a steady, upward climb in the prevalence of diabetes, although data from the last 3 years shows a leveling of the prevalence.

Hawaii healthiest state third year running

The state out on top for the third consecutive year is Hawaii, while Mississippi ranks 50th and least healthy, also for the third year in a row. But what makes these two states rank as the extreme bookends, and how well do other states fare in various shades in the middle?

Hawaii has consistently been a steady high contender in the top six states since the initiation of the rankings in 1990, due to its low prevalence of both smoking and obesity; a low percentage of children in poverty; small disparity in health status by education level; and low rates of preventable hospitalizations, cancer deaths and cardiovascular deaths.

Following Hawaii in the top 10 healthiest states is:

1. Hawaii
2. Vermont
3. Massachusetts
4. Connecticut
5. Utah
6. Minnesota
7. New Hampshire
8. Colorado
9. North Dakota
10. Nebraska.

The challenges faced by Hawaii are a high prevalence of binge drinking, at 18.3% of the adult population; a high incidence of Salmonella infections, at 24.7 cases per 100,000 population; and low immunization coverage among children.

Mississippi, however, ranks better for low prevalence of binge drinking, high immunization coverage among children, and small disparity in health status. Nevertheless, it ranks in the bottom 5 states on 16 of the 27 measures including a high prevalence of obesity, physical inactivity, diabetes, children in poverty and low birthweight infants; low high school graduation rate; limited availability of primary care physicians and dentists; and a high incidence of infectious disease.

Following Mississippi in the 10 lowest ranking states in terms of health is:

1. Mississippi
2. Arkansas
3. Louisiana
4. Kentucky
5. Oklahoma
6. Tennessee
7. West Virginia
8. Alabama
9. South Carolina
10. Indiana.

The awards for the biggest improvers since 2013 go to Maryland, gaining eight places, Texas and Virginia up five places and Alabama, California, Rhode Island and South Dakota rising four positions.

Those declining since last year include Wyoming falling eight places, Idaho and Iowa moving down six and Delaware and Maine dropping four.

The most surprising improvement since 1990 is New York. Once down in the depths ranking at 40, it has leaped 26 places up to 14 in 2014.

States leading and lagging in each category

What are the building blocks of health? The report says in addition to the contributors of our individual genetic predispositions to disease, health is:

1. A result of our behaviors
2. The environment and community in which we live
3. The policies and practices of our health care, government and other prevention systems
4. The clinical care we receive.

These four aspects interact with each other in a complex web of cause and effect, and much of this interaction is just beginning to be fully understood. Below are a list of elements of these key aspects and the winners and losers in each area. The first state featured ranks at the top and the second state at the bottom in each category.

Behaviors

• Smoking: Utah 10.3%/West Virginia 27.3%
• Binge drinking: Tennessee 9.6%/North Dakota 23.8%
• Drug deaths: North Dakota 3.0/West Virginia 31.3 (per 100,000 population)
• Obesity: Colorado 21.3%/West Virginia 35.1%
• Physical inactivity: Colorado 16.2%/Mississippi 35.2%
• High school graduation: Nebraska 93%/Nevada 60%.

Community and environment

• Violent crime: Maine 123/Tennessee 644 (cases per 100,000 population)
• Occupational fatalities: Massachusetts 2.2/Wyoming 12.5 (per 100,000 workers)
• Children in poverty: Utah 9.2%/Kentucky 31.8%
• Air pollution: Alaska 4.9/California 13.9 (average exposure of the general public to particulate matter of 2.5 microns or less in size)
• Chlamydia: New Hampshire 233.0/Mississippi 774.0 (new cases per 100,000 population)
• Pertussis: Louisiana 1.6/Wisconsin 120.5 (new cases per 100,000 population)
• Salmonella: Nevada 6.8/Arkansas 47.8 (new cases per 100,000 population).

Policy

• Lack of health insurance: Massachusetts 3.8%/Texas 22.3%
• Public health funding: Alaska $219/Nevada $39 (state dollars dedicated to public health and federal dollars directed to states by CDC and the HRSA)
• Child immunization: Rhode Island 82.1%/Arkansas 57.1%
• Adolescent immunization: Rhode Island 81.3%/Mississippi 45.2%.

Clinical care

• Low birthweight: Alaska 5.7%/Mississippi 11.6%
• Primary care physicians: Massachusetts 200.8/Idaho 80.1 (number of primary care physicians, including general practice, family practice, OB-GYN, pediatrics and internal medicine per 100,000 population)
• Dentists: Massachusetts 85.6/Arkansas 41.7 (number of practicing dentists per 100,000 population)
• Preventable hospitalizations: Hawaii 28.2/Kentucky 94.4 (discharge rate of Medicare beneficiaries from hospitals for ambulatory care-sensitive conditions).

Outcomes

• Diabetes: Colorado 6.5%/Alabama 13.8%
• Poor mental health days: South Dakota 2.5/Kentucky 4.5 (number of days in the past 30 days adults report their mental health was not good)
• Poor physical health days: South Dakota 2.8/West Virginia 5.3 (number of days in the past 30 days adults report their physical health was not good)
• Disparity in health status: Hawaii 15.5/California 38.6 (difference in the percentage of adults with versus without a high school degree who report their health is very good or excellent)
• Infant mortality: Massachusetts 4.2/Mississippi 9.1 (number of infant deaths before age 1 per 1,000 live births)
• Cardiovascular deaths: Minnesota 184.7/Mississippi 346.0 (per 100,000 population)
• Cancer deaths: Utah 145.7/Kentucky 228.3 (per 100,000 population)
• Premature deaths: Massachusetts 5,345/Mississippi 10,354 (number of years of potential life lost prior to age 75 per 100,000 population).

Steady rise in chronic conditions over 25 years

With life expectancy currently at 79 years in the US, we rank at 34th in the world. While we are living longer, the past 25 years have seen a steady rise in chronic conditions – many of them preventable – that compromise our quality of life.

Anna Schenck, PhD, MSPH, Chair, America’s Health Rankings Scientific Advisory Committee, Director, Public Health Leadership Program, UNC Gillings School of Global Public Health, says:

“US health outcomes are much worse than most other developed countries despite spending a greater percentage of our resources [on] health care than all other countries. We have an opportunity to make dramatic improvements [in] health if we focus on prevention. This type of opportunity only comes around once in a generation. Now is the time.”

What can each one of us do to boost our state and world rankings? The report highlights several measures that we can include in our everyday lives to improve our health, prevent disease onset and perhaps extend life expectancy:

• Avoid excessive drinking
• Avoid smoking
• Avoid drug use
• Keep prescription drugs in a secure place
• Regular health checks
• Check cholesterol regularly
• Monitor blood pressure
• Annual dental visit
• Healthy diet
• Maintain a healthy weight
• Consume 5 or more servings of fruits and vegetables per day
• Sleep for 7-8 hours per night
• Increase physical activity
• Control blood sugar
• Eat less salt
• Prepare food safely
• Reduce teen pregnancy through education
• Practice safe sex
• HIV testing for pregnant women
• Folic acid supplements during pregnancy
• Breastfeed if you can
• Put baby to sleep on their back
• Stay in school
• Get immunized
• Avoid pesticides
• Avoid tanning beds
• Manage stress
• Wash hands
• Get vaccinated
• Get booster shots.

“The Rankings were founded 25 years ago on the idea that we cannot improve what we cannot measure,” claims Kate Rubin, president of United Health Foundation. “Looking ahead to the next 25 years, United Health Foundation is committed to providing a continued roadmap for health improvement through deep, comprehensive reporting that shows where we have made progress and where there is work to be done.”