Americas Health Rankings 2012 v1

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A CALL TO ACTION FOR INDIVIDUALS
AND THEIR COMMUNITIES
2012 EDITION
The United Health Foundation provides reliable
information to support health and medical
decisions that lead to better health outcomes
and healthier communities. The Foundation also
supports activities that expand access to quality
health care services for those in challenging
circumstances and partners with others to
improve the well-being of communities.
United Health Foundation
9900 Bren Road East
Minnetonka, MN 55343
www.unitedhealthfoundation.org
Americas Health Rankings
is available in its entirety

at www.americashealthrankings.org. Visit the website
to request or download additional copies.
DECEMBER 2012
Our Partners:
Components of Health
The World Health Organization denes health as a state of complete
physical, mental and social well-being and not merely the absence of
disease or inrmity.
In addition to the contributions of our individual genetic predispositions
to disease, health is the result of:
Cur behavlors
The envlronmenf and fhe communlfy ln whlch we llve
The pollcles and pracflces ol our healfh care, governmenf and ofher
prevention systems
The cllnlcal care we recelve
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. Understanding these interactions is vital if we are to create
the healthy outcomes we desire, including a long, disease-free, robust
life for all individuals regardless of race, gender, or socio-economic
status. This report focuses on these determinants and on the overall
health outcomes we desire.
At americashealthrankings.org, you can nd information about the
health of your state compared to other states, build custom reports to t your
needs, and download templates and graphs to share with others. Stay informed
throughout the year by signing up for the newsletter and reading the AHR blog.
Keep up with Americas Health Rankings
via Facebook and Twitter. Youll

see how everyone is working in real time to help improve the health of our
communities, workplaces, states, and nation.
Americashealthrankings.org/newsletter facebook.com/AmericasHealthRankings twitter.com/AHR_Rankings
TAKE ACTION
For you and your community
1. Visit americashealthrankings.org/takeaction to learn what
you can do to improve your communitys health.
3. Review results and decide on
the actions you can take.
2. Select what you want to
improve and click Go.
2012 EDITION
2012 Edition is available in its entirety at

www.americashealthrankings.org. Visit the site to request or download
additional copies.
2012 Edition is a joint effort of United Health

Foundation (www.unitedhealthfoundation.org), the American Public Health Association
(www.apha.org) and Partnership for Prevention (www.prevent.org). It is funded entirely
by United Health Foundation, a recognized 501(c)(3) organization.
Data contained within this document was obtained from and used with permission of:
U.S. Department of Health and Human Services
Centers for Disease Control and Prevention
National Center for Health Statistics
U.S. Department of Commerce
Census Bureau
Bureau of Economic Analysis
U.S. Department of Education
National Center for Education Statistics
U.S. Department of Labor
Bureau of Labor Statistics
U.S. Environmental Protection Agency
American Medical Association
The Dartmouth Atlas Project
Trust for Americas Health
World Health Organization
United Health Foundation, the American Public Health Association, and Partnership
for Prevention encourage the distribution of information contained in this publica-
tion for non-commercial and charitable, educational, or scientic purposes. Please
acknowledge Americas Health Rankings
2012 Edition as the source and provide

the following notice: 2012 United Health Foundation. All Rights Reserved. Please
acknowledge the original source of specic data as cited.
This project was conducted for and in cooperation with United Health Foundation, the
American Public Health Association, and Partnership for Prevention by Arundel Street
Consulting, Inc., St. Paul, Minn.
Design by Aldrich Design, St. Paul, Minn.
Questions and comments on the report should be directed to United Health
Foundation at unitedhealthfoundationinfo@uhc.com
Copyright 2012 United Health Foundation
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Acknowledgment
Commentaries
On the Front Lines: Celebrating Americas Public Health Professionals,
Reed V. Tuckson, M.D., Medical Advisor, United Health Foundation;
Executive Vice President and Chief of Medical Affairs,
UnitedHealth Group
The Guidebook for Healthy Communities and Healthy States,
John M. Clymer; Jonathan E. Fielding, M.D., M.P.H., M.B.A., M.A.;
Barbara K. Rimer, Dr.P.H.; Nico P. Pronk, Ph.D
Introduction
Purpose
Scientic Advisory Committee
Findings
National Perspective
Health Disparities within States
Comparison to Other Nations
Methodology
Weighting of Measures
Impact of Model Changes
Revised BRFSS Methodology
Measures
Selection of Measures
Determinants and Outcomes
Description of Measures
Health Determinants
Health Outcomes
Supplemental Measures
Index of Tables, Figures and Graphs
State-by-State Snapshots
Commentaries
Promoting the Publics Health in Louisiana, David Heitmeier, O.D.,
Louisiana State Senator, Louisiana State Legislature, District 7; Karen B.
DeSalvo, M.D., M.P.H., M.Sc., Health Commissioner, City of New Orleans
Improving Health Outcomes: the Role of State Health Leadership,
Paul E. Jarris, M.D., M.B.A., Executive Director, Association of State and
Territorial Health Ofcials
Americas Declining Health is Opportunity for Medical and Community
Partnerships, Jeremy A. Lazarus, M.D., American Medical Association
Take It Outside: the Health Benets of Parks, Chris Kay, Chief Operating
Ofcer, The Trust for Public Land
The Answer is Prevention, Eduardo Sanchez, M.D., M.P.H., F.A.A.F.P.,
Chairman, Partnership for Prevention
Improving Health Through the Places We Live, Work, and Play, Georges
Benjamin, M.D., Executive Director, American Public Health Association
Table of Contents
at United Health Foundation,
along with our partners at
the American Public Health
Association and Partnership for Prevention, are
pleased to present the 23rd Edition of Americas
Health Rankings
: A Call to Action for Individuals

and Their Communities. First published in 1990,
provides the longest-

running state-by-state analysis of our countrys
health and the factors that affect it.
This year, the report benets from updated
data collection technologies and analysis. Some
of the measures that we use in
the report are provided by the
CDCs Behavioral Risk Factor
Surveillance System. This is
the largest health survey in the
world and now, for the rst time,
includes the addition of cell
phone-only households. Adding
these individuals ensures that
groups who may only have a cell
phone are included in the survey,
thus giving all of us a more accu-
rate picture of the nations health. The CDC found
four demographic groups in which the majority live
in households without landlines:
Adulfs aged 25-34
Adulfs llvlng only wlfh unrelafed roommafes
Adulfs renflng fhelr home
Adulfs llvlng ln poverfy
Because of this enhanced and modied data col-
lection method, unlike in previous editions, we are
unable to make certain year-to-year comparisons.
As such, this years report will serve as the new
baseline for future reports. We hope that our faith-
ful readers and stakeholders will understand and
be patient as we recalibrate our data for even more
accurate longitudinal tracking in the years to come.
When we look at this years report, we see that
we are living longer, but with an increasing burden
of preventable chronic illness. In particular, our
nations health is persistently compromised by risk
factors such as sedentary behavior, obesity, and
diabetes. Additionally, social indicators like children
in poverty, high school graduation, and the rate of
uninsured population are also not improving. And,
while multiple data sets indicate that the hard work
of many has resulted in lower rates of smoking, far
too many people continue to be exposed to this
number one risk factor for preventable disease.
It has become clear to most of you by now
that risk factors lead to disease, and the medical
treatment of disease comes with an increasingly
expensive price tag. Our nations private corpora-
tions and small businesses; federal, state and local
governments; and individuals and families are all
increasingly burdened by the economic costs and
productivity consequences of preventable illness.
Data from sources such as the Trust for Americas
Health report F as in Fat: How Obesity Threatens
Americas Future 2012 indicates that obesity alone
cosfs our naflon befween $147 bllllon and $210 bll-
lion each year. Add the direct and indirect costs for
diabetes, heart disease, and other chronic illnesses,
and the urgency for effective, sustained, and multi-
stakeholder action becomes unavoidable.
As such, the subtitle of this report remains A Call
to Action for Individuals and Their Communities.
As we have said in years past, we are all in this
together. Governments and public health depart-
ments cannot do it alone, which is why we are
looking forand supportingopportunities and
innovative best practices to engage the private
sector, philanthropies, community organizations,
and individuals in sustained collaborative partner-
ships for health.
Many of the commentaries in this years report
reect the need for multi-stakeholder solutions
and action. This year we are honored to have
commentaries from the following individuals and
organizations:
On the Front Lines: Celebrating Americas
Public Health Professionals, authored by Reed V.
Tuckson, M.D., who discusses the important role
of public health professionals who work tirelessly
to promote health and prevent disease.
The Guidebook for Healthy Communities and
Healthy States, authored by John M. Clymer;
Jonathan E. Fielding, M.D., M.P.H., M.B.A., M.A.;
Barbara K. Rimer, Dr.P.H.; Nico P. Pronk, Ph.D.*,
who discuss The Guide to Community Preventive
Services and its role in highlighting effective
strategies, programs, and policies to improve
health.
Promoting the Publics Health in Louisiana,
authored by Senator David Heitmeier, O.D., and
Karen DeSalvo, M.D., who discuss their efforts to
We
Americas Health
Rankings
provides
the longest-running
state-by-state
analysis of our
countrys health.
Acknowledgment
2 www. a mer i c a s hea l t hr a nk i ngs . or g
improve Louisianas ranking to 35th over the next
few years.
Improving Health Outcomes: The Role of State
Health Leadership, authored by Paul E. Jarris,
M.D., M.B.A., Association of State and Territorial
Health Ofcials, who presents promising strate-
gies to improve the health of our nation.
Americas Declining Health is Opportunity for
Medical and Community Partnerships, authored
by Jeremy A. Lazarus, M.D., American Medical
Association, who speaks to the inuential role
of physicians and other health care providers in
addressing key determinants of health in clinical
practice and at the community level.
Take It Outside: the Health Benets of Parks,
authored by Chris Kay, The Trust for Public Land,
who discusses the role his organization is playing
to help ght obesity.
The Answer is Prevention, authored by Eduardo
Sanchez, M.D., M.P.H., F.A.A.F.P., Partnership for
Prevention, who highlights the importance of
prevention in improving health.
Improving Health Through the Places We Live,
Work, and Play, authored by Georges Benjamin,
M.D., American Public Health Association, who
highlights steps all of us can take to improve the
health of our nation.
We invite you to share proven or innovative
programs that have made a difference in your com-
munity by emailing unitedhealthfoundationinfo@
uhc.com, posting on our Facebook page at www.
facebook.com/AmericasHealthRankings, or tweet-
ing to us on Twitter at @AHR_Rankings. A healthy
exchange of ideas allows all of us to share informa-
tion, learn from one another, and work together to
address our nations health challenges and improve
the lives of all.
We appreciate the hard work, collaboration,
expertise, and guidance provided by our Scientic
Advisory Committee, composed of leading public
health scholars and led by Anna Schenk, Ph.D.,
M.S.P.H., Director of the Public Health Leadership
Program and North Carolina Institute for Public
Health for the Gillings School of Global Public
Health at the University of North Carolina at
Chapel Hill. This report remains relevant and robust
because they review, debate, discuss, and modify
the reports methodological framework to ensure
that it most accurately reects the nations health.
This year, we give special thanks to the dedi-
cated public health professionals who serve our
nation. Without them, we would be a nation that
is sicker, less prepared for emergencies, and more
vulnerable to threatsbe they natural or man-
made. These dedicated health professionals work
tirelesslyand too often thanklesslyon behalf of
Americans every day. They deserve the apprecia-
tion of the American people!
*All authors are members of the Community Preventive Services
Task Force; Clymer is Executive Director of the National Forum
for Heart Disease & Stroke Prevention; Fielding is Director of
Public Health, Los Angeles County; Rimer is Dean, University
of North Carolina at Chapel Hill Gillings School of Global
Public Health; Pronk is Vice President for Health Management,
HealthPartners.
A M E R I C A S H E A L T H R A N K I N G S 3
Acknowledgement
Eduardo Sanchez, M.D., M.P.H., F.A.A.F.P.
Chairman, Partnership for Prevention
Reed V. Tuckson, M.D.

Medical Advisor, United Health Foundation;
Executive Vice President and Chief of Medical
Affairs, UnitedHealth Group
Georges C. Benjamin, M.D.
Executive Director
American Public Health Association
Commentaries
is almost impossible in todays world
to avoid a news story or conversation
about some health-related issue or
another. It seems that each day brings reports of
a new scientic discovery; a lifesaving tech-
nological innovation; escalating concerns about
the cost of health care; or the
myriad details concerning
health policy challenges and
legislative choices associated
with expanding access to
health care for our nations
citizens. Unfortunately, too
often lost and taken for
granted in the maze of all
this is the essential efforts
of the 450,000 public health
professionals who work tire-
lessly behind the scenes to
promote health and prevent
disease. Despite their hard
work, support for our nations
vital public health infrastruc-
ture at the federal, state, and
local levels may be at risk
and, as a result, so too is the
health and the nancial well-
being of our nation.
According to recent
reports by the Institute of
Medicine of the National
Academy of Sciences, public
health can be dened as
those activities that fulll
societies interest in assuring conditions in
which people can be healthy through organized
community efforts aimed at the prevention of
disease and promotion of health. Achieving the
mission of public health requires an inclusive-
ness of engagement that involves the medical
care delivery system; the private sector; com-
munity organizations; departments of community
development and planning; philanthropies; the
media; recreation agencies; housing authorities;
and other social stakeholders. In essence, the
work of public health involves signicant coordi-
native functions in addition to its own activities
such as conducting mass vaccination campaigns;
producing PSAs to encourage healthy behaviors
and reduction in injuries; conducting disease
and bioterrorism-related surveillance; ensuring
safe water supplies; and working with pregnant
women to deliver healthy babies.
The work of public health today is as important
to each American and to our nation as a whole
as it has ever been in our history. While we are
blessed with an extraordinary lifesaving arma-
mentarium of medical technology interventions,
the medical treatment of illnesses is becoming
more costly and unaffordable with each passing
day. Unfortunately, as a result of our failure to
optimally prevent illness and promote health, we
are experiencing an ever expanding number of
people who are living with preventable chronic
illnesses that require treatment in an ever more
expensive care delivery system. This is simply
incompatible with the best interests of individu-
als and our society. We must do more to tackle
mission of
public health
requires an
inclusiveness of
engagement.
REED V. TUCKSON, M.D.
Medical Advisor, United Health Foundation
Executive Vice President and
Chief of Medical Affairs, UnitedHealth Group
On the Front Lines: Celebrating Americas
Public Health Professionals
the preventable risk factors for disease such as
a persistently high level of tobacco use and the
dramatic escalations in diabetes and obesity.
These and other challenges create urgency for all
of us across society to embrace public health, its
dedicated professionals, and its infrastructure.
Sometimes it helps to put a face on an issue.
Let me introduce you to Dr. Marion Kainer, the
director of health care associated infections for
the Tennessee Department of Health. Recently,
she was among the rst to notice a suspicious
case of meningitis associated with an injectable
compound. Utilizing her experience from years
of disease detective work, she was key to quickly
unraveling what we have now come to under-
stand as a nationwide emergency associated with
fungal contamination of drugs made by a medi-
cal compounding pharmacy in another state. Her
personal diligence and collaboration with other
expert professionals at the federal Centers for
Disease Control and Prevention and The Food
and Drug Administration undoubtedly blunted
what would have been a major catastrophe. In
addition to Dr. Kainers impressive skills, without
a coordinated public health infrastructure and the
engagement of stakeholders across the nation,
she would not have been successful and many
more people would have suffered.
I am proud that early in my career, I was fortu-
nate to be a member of our nations public health
army. As a nation, we now face increasing levels
of preventable illness, serious medical care afford-
ability and access issues, and difcult choices
regarding the allocation of public resources. I
Dr. Marion Kainers
personal diligence
and collaboration
with other expert
professionals
undoubtedly
blunted what
would have been a
major catastrophe.
urge all of us to do
what we can through
our individual efforts
to promote our own
health, the health of
our families, and the
health of our com-
munities. We should
also engage the
institutions with which
we are afliated to
celebrate and collabo-
rate with local public
health professionals
in our shared goal to
ensure the conditions
necessary for our fami-
lies and communities to be healthy.
To our nations 450,000 public health profes-
sionals, thanks for all that you do for each of us
every day!
R
egardless of your states rank, there are
great opportunities to improve the health
of its population. As you look for strate-
gies, programs or policies to improve health, the
Community Guide (www.thecommunityguide) is an
indispensible resource.
The Community Guide is a one-stop source of
programs, services and policies that have been
proven to protect and improve health at the
population level in a variety of settingssuch
as worksites, schools, health plans, health care
systems, faith-based institutions, communities,
and states. It includes interventions to prevent risk
factors for asthma, cancer, diabetes, heart disease,
and stroke; prevent the spread of infectious
diseases; reduce motor vehicle injury and health
disparities; and improve mental health.
methodology
recognizes that multiple factors inuence health.
Their approximate contribution to the publics
health are: behavioral factors (40%), genet-
ics (30%), social circumstances (15%), medical
care (10%) and environmental conditions (5%).
i
Community preventive efforts such as those in the
Community Guide can make a difference in several
important ways:
Increase healthy longevityTodays youth
could be the rst generation to live shorter
and less healthy lives than their parents
ii
or, if
healthier choices are made easier, they could
enjoy even greater vitality and longer functional
independence than their parents.
Reduce illness burdenMany Americans suffer
from preventable, costly chronic conditions,
such as diabetes, for decades.
ii i
The Guidebook for Healthy
Communities and Healthy States
JOHN M. CLYMER; JONATHAN E. FIELDING, M.D., M.P.H., M.B.A., M.A.;
BARBARA K. RIMER, Dr.P.H.; NICO P. PRONK, Ph.D.*
Reduce the likelihood of becoming ill
Protecting peoples health by preventing
diseases makes sense and can save money.
i v
Reduce healthcare spendingCommunity-
based disease prevention efforts can help
restrain the growth in healthcare spending by
reducing both the need and demand for clinical
services.
v
Make healthy choices easy choicesMaking
healthy choices is easier with access to options
such as healthy food, safe sites for physical
activity and recreation, and smoke-free
environments.
v i
Maintain or improve economic vitalityA
healthy, vibrant community is a productive com-
munity with a resilient workforce and economic
vitality. Healthy, safe communities may help
states attract new employers and industries,
create jobs, increase housing values, enhance
community prosperity, and support global
competitiveness.
v i i
Reduce wasteImplementing Task Force-
recommended programs and services can
increase delivery of recommended clinical
preventive services in multiple settings
Commentaries
i McGinnis JM, Russo P, Knickman JR. The case for more active
policy attention to health promotion. Health Affairs 21, no.
2 (2002): 78-93; some estimates are even higher: see Booske
BC, Athens JK, Kindig DA et al. Different Perspectives for
Assigning Weights to Determinants of Health. County Health
Rankings Working Paper. University of Wisconsin Population
Health Institute, February 2010. <http://uwphi.pophealth.wisc.
edu/publications/other/differentPerspectivesForAssigning-
WeightsToDeterminantsOfHealth.pdf> (accessed September
22, 2011)
ii Olshansky SJ, Passaro DJ, Hershow RC et al. A potential
decline in life expectancy in the United States in the 21st
century. New England Journal of Medicine 352, no. 11 (2005):
11381145; and Reither EN, Olshansky SJ, Yang Y. New
forecasting methodology indicates more disease and earlier
mortality ahead for todays younger Americans. Health Affairs
30, no. 8 (2011): 1562-1568.
The Community
Guide is a one-
stop source of
programs, services
and policies that
have been proven
to protect and
improve health.
(e.g., clinics, worksites, schools), reducing
the healthcare services otherwise needed
for preventable conditions and related produc-
tivity losses.
v i i i
Enhance national securityAccording to the
2010 Mission: Readiness report, Too Fat to
Fight, obesity is the leading medical reason
why unprecedented numbers of young men and
women fail to qualify for military service.
i x
Prepare communities for emergenciesFirst
responders and public health workers are
fortied with evidence-based guidelines for
responding to tornadoes, hurricanes, oods,
other natural disasters, infectious disease out-
breaks, and other threats.
x
Empower individuals, families, employers,
schools, and communitiesPutting community
preventive services into practice provides infor-
mation, resources, skills, and environments in
which people, communities, and organizations
can thrive.
xi
Community Guide programs, services and
policies really work. For example:
Wlfhln one year alfer Duval Counfy, Florlda
implemented several Community Guide recom-
mendations for increasing immunization rates,
these rates increased from 75% to 90%.
xi i
Mlnnesofa, already one ol fhe healfhlesf sfafes
in the U.S., wanted to reduce the burden of
chronic disease on the state and its people.
Blue Cross Blue Shield of Minnesota (BCBSM)
used Community Guide recommendations in
a long term initiative to increase adults physi-
cal activity, improve their nutrition, and reduce
smoking and exposure
to secondhand tobacco
smoke. As a result of col-
lective efforts by BCBSM
and others, Minnesotas
heart disease rate
declined by 9 percent
over a three-year period,
as physical activity
increased and tobacco
use decreased.
xi i i
All interventions in
the Community Guide
are recommended by
iii McGinnis JM, Foege WH. Actual causes of death in the United
States. Journal of the American Medical Association 270, no.
18 (1993): 2207-2212; and Mokdad AH, Marks JS, Stroup DF,
Gerberding JL. Actual causes of death in the United States,
2000. Journal of the American Medical Association 291, no.
10 (2004): 1238-1245, corrections 293, no.3 (2005): 298; World
Health Oganization. Global Status Report on Noncommunicable
Diseases, 2010. Geneva: World Health Organization, 2011.
<http://www.who.int/nmh/publications/ncd_report2010/en/
index.html> (accessed September 23, 2011).
iv Trust for Americas Health. Prevention for a Healthier America:
Investments in Disease Prevention Yield Signicant Savings,
Stronger Communities. Washington, DC: Trust for Americas
Health, February 2009. <http://healthyamericans.org/reports/
prevention08/Prevention08.pdf > (accessed November 6, 2012).
v Milstein B, Homer J, Briss P et al. Why behavioral and envi-
ronmental interventions are needed to improve health at lower
cost. Health Affairs 30, no. 5 (2011): 823-832.
vi See, for example, Centers for Disease Control and
Prevention. Best Practices for Comprehensive Tobacco
Control Programs2007. Atlanta: U.S. Department of Health
and Human Services, Centers for Disease Control and
Prevention, National Center for Chronic Disease Prevention
and Health Promotion, Ofce on Smoking and Health,
October 2007. Reprinted with corrections. <http://www.cdc.
gov/tobacco/stateandcommunity/best_practices/index.
htm> (accessed November 6, 2012); Keener D, Goodman K,
Lowry A et al. (2009). Recommended Community Strategies
and Measurements to Prevent Obesity In the United States:
Implementation and Measurement Guide. Atlanta, GA:
U.S. Department of Health and Human Services, Centers
for Disease Control and Prevention. <http://www.cdc.gov/
obesity/downloads/community_strategies_guide.pdf>
(accessed November 6, 2012).
the Community Preventive Services Task Force,
a Congressionally mandated independent blue
ribbon panel of health experts appointed by the
Director of the Centers for Disease Control and
Prevention. The Task Force bases its recommen-
dations on systematic reviews of evidence. It is
advised by scientists and program staff from the
CDC and other agencies and institutions, plus of-
cial liaisons from medical and health professional
vii Cawley J, Ruhm C. The Economics of Risky Health Behaviors.
National Bureau of Economic Research Working Paper No.
17081, May 2011; Goetzel RZ, Kowlessar N, Roemer EC et
al. Workplace Obesity Programs. Chapter 8 in The Oxford
Handbook of the Social Science of Obesity, edited by Cawley,
J. New York: Oxford University Press, Inc., 2011; Goetzel
RZ, Ozminkowski RJ. The health and cost benets of work
site health-promotion programs. Annual Review of Public
Health 29, (2008): 303-323; Stiglitz JA, Sen A, Fitoussi J-P.
2009. Report by the Commission on the Measurement of
Economic Performance and Social Progress. Paris, France:
Commission on the Measurement of Economic and Social
Progress. <http://www.stiglitz-sen-toussi.fr/documents/rap-
port_anglais.pdf> (accessed November 6, 2012).
viii Fielding JE, Teutsch SM. Integrating clinical care and com-
munity health: delivering health. Journal of the American
Medical Association, 302, no. 3 (2009): 317-319; Ockene
JK, Edgerton EA, Teutsch SM et al., Integrating evidence-
based clinical and community strategies to improve health.
American Journal of Preventive Medicine 32, no.3 (2007): 244-
252; See also the discussion of tobacco cessation interventions
in Centers for Disease Control and Prevention. Best Practices
for Comprehensive Tobacco Control Programs2007. Atlanta:
U.S. Department of Health and Human Services, Centers for
Disease Control and Prevention, National Center for Chronic
Disease Prevention and Health Promotion, Ofce on Smoking
and Health, October 2007. Reprinted with corrections. <http://
www.cdc.gov/tobacco/stateandcommunity/best_practices/
index.htm> (accessed November 6, 2012)
ix Mission: Readiness. Too Fat to Fight: Retired Military Leaders
Want Junk Food Out of Americas Schools. Washington, DC:
Mission Readiness, 2010. <http://cdn.missionreadiness.org/
MR_Too_Fat_to_Fight-1.pdf> (accessed November 6, 2012).
x Trust for Americas Health. Ready or Not? Protecting the
Publics Health from Diseases, Disasters, and Bioterrorism.
Washington, DC: Trust for Americas Health, 2010. < http://
healthyamericans.org/assets/les/TFAH2010ReadyorNot%20
FINAL.pdf > (accessed November 6, 2012).
xi Brownson RC, Baker EA, Leet TL et al. Evidence-Based Public
Health, 2nd ed. New York: Oxford University Press, Inc., 2011;
Fielding JE, Hopkins DP. An introduction to evidence on
worksite health promotion. Chapter 9 in American College
of Sports Medicines Worksite Health Handbook: A Guide to
Building Healthy and Productive Companies, edited by Pronk
NP, 75-81. Champaign, Illinois: Human Kinetics, 2009
xii The Community Guide. A Good Shot: Reaching Immunization
Targets in Duval County, The Community Guide in Action,
The Community Guide. 2012. < http://www.thecommuni-
tyguide.org/CG-in-Action/Vaccinations-FL.pdf> (accessed
November 7, 2012)
xiiiThe Community Guide. Evidence-based Recommendations
Get Minnesotans in the Groove, The Community Guide in
Action, the Community Guide. 2012 < http://www.thecom-
munityguide.org/CG-in-Action/PhysicalActivity-MN.pdf>
(accessed November 7, 2012)
*All authors are members of the Community Preventive Services Task Force; Clymer is Executive Director of
the National Forum for Heart Disease & Stroke Prevention; Fielding is Director of Public Health, Los Angeles
County; Rimer is Dean, University of North Carolina at Chapel Hill Giddings School of Global Public Health;
Pronk is Vice President for Health Management, HealthPartners.
societies and organizations such as the Association
of State and Territorial Health Ofcials and
National Association of County and City Health
Ofcials. Task Force recommendations provide a
menu of effective programs, services, and policies
from which decision makers can select those that
best meet the unique needs, constraints, and avail-
able resources of their community and state.
Commentaries
Figure 1
Introduction
Introduction
Health is a result of our behaviors, our individual
genetic predisposition to disease, the environment
and the community in which we live, the clinical
care we receive, and the policies and practices of
our health care, government, and other prevention
systems. Each of us individually, as a commu-
nity, and as a society strives to optimize these
health determinants, so that all of us can have a
long, disease-free and robust life regardless of
race, ethnicity, gender, or socio-economic status.
This report looks at the four groups of health
determinants that can be affected:
1. Behaviors include the everyday activities we
do that affect our personal health. It includes
habits and practices we develop as individuals
and families that have an effect on our per-
sonal health and on our utilization of health
resources. These behaviors are modiable with
effort by the individual supported by commu-
nity, policy, and clinical interventions.
2. Community and environment reect the reality
that the daily conditions in which we live our
lives have a great effect on achieving optimal
individual health. These factors can be modied
by a concerted effort by the community and its
elected ofcials, supported by state and federal
agencies, professional associations, advocacy
groups, and businesses.
3. Policy inuences the availability of resources
to encourage and to maintain health and the
extent that public and health programs reach
into the general population. Policies can have
very wide reach throughout the state and pro-
mote healthy living and judicious consumption
of health care resources.
4. Clinical care reects the quality,
appropriateness, and cost of care we receive at
doctors ofces, clinics, and hospitals.
All health determinants are intertwined and must
work together to be optimally effective. For exam-
ple, an initiative that addresses
tobacco cessation requires
not only efforts on the part of
the individual but also support
from the community in the form
of policies that promote non-
smoking and the availability of
effective counseling and care at
clinics. Similarly, reducing the
risk of having a low birthweight
baby requires individual effort,
education, access to and avail-
ability of prenatal care, coupled
with high quality health care services. Addressing
obesity, a health epidemic now facing this country,
requires coordination among almost all sectors of
Each of us
individually, as
a community,
and as a society
strives to
optimize health.
the economy including food producers, dis-
tributors, restaurants, grocery and convenience
stores, exercise facilities, parks, urban and trans-
portation design, building design, educational
institutions, community organizations, social
groups, health care delivery, and insurance to
complement and augment individual actions.
combines individ-
ual measures of each of these determinants with
the resultant health outcomes into one compre-
hensive view of the overall health of a state.
employs a unique
methodology, developed and periodically
reviewed by a panel of leading public health
scholars, which balances the contributions of var-
ious factors such as smoking, obesity, sedentary
lifestyle, binge drinking, high school graduation
rates, children in poverty, access to care, and
incidence of preventable disease, to a states
health. The report is based on data from the U.S.
Departments of Health and Human Services,
Commerce, Education, Justice and Labor; U.S.
Environmental Protection Agency; U.S. Census
Bureau; the American Medical Association;
the Dartmouth Atlas Project; and the Trust for
Americas Health.
The 2012 Edition of Americas Health
Rankings
is considered a benchmark of the

relative health of states due to its longevity and
its sound model. Numerous states incorporate
this report into their annual review of programs,
and several organizations use this study as a
reference point when assigning goals for health
improvement programs.
Purpose
The ultimate purpose of Americas Health
Rankings
.
is to stimulate action by individuals,
elected ofcials, medical professionals, public
health professionals, employers, educators,
and communities to improve the health of the
population of the United States. We do this by
promoting public conversation concerning health
in our states, as well as providing information to
facilitate citizen, community, and group participa-
tion. We encourage participation in all elements:
behaviors, community and environment, clinical
care, and policy. Each person individually, and in
their capacity as an employee, employer, educa-
tor, voter, community
volunteer, medical
professional, public
health ofcial or elected
ofcial, can contribute
to the advancement of
the healthiness of their
state. Proven, effective,
and innovative actions
can improve the health
of people in every state
whether the state is
ranked rst or 50th.
The ultimate
purpose of
Americas
Health
Rankings
is
to stimulate
action.
Scientic Advisory Committee
Scientic Advisory
Committee
In 2002, United Health Foundation, in concert with
the American Public Health Association (APHA)
and Partnership for Prevention, commissioned the
School of Public Health at the University of North
Carolina at Chapel Hill to undertake an ongo-
ing review of Americas Health Rankings
. The
Scientic Advisory Committee is charged with
recommending improvements that will maintain
the value of the comparative, longitudinal informa-
tion; reect the evolving role and science of public
health; utilize new or improved measures of health
as they become available and acceptable; and
incorporate new methods as feasible. Minor issues
with data are always addressed immediately and
incorporated into the contents of the next edition
of the report. However, more signicant issues,
such as new measurements of health conditions,
require more in-depth study and analysis.
The Scientic Advisory Committee, led by Anna
Schenck, Ph.D., M.S.P.H., continues its review, and
its input is reected in this Edition. The Committee
emphasizes the importance of this tool as a vehicle
to promote and improve the general discussion
of public health and, also, to encourage balance
among public health efforts to benet the entire
community.
This Edition includes changes recommended by
the committee:
lnclude sedenfary lllesfyle as a behavlor fo
reect the impact that lack of physical activity
has on our nations health
Replace early prenafal care, whlch ls nof mea-
sured consistently across the states, with low
birthweight as a clinical care indicator, which is
collected uniformly across states
In addition, the committee continues to work on
issues concerning improved environmental health
indicators; quality and availability of healthy foods;
exercise and activity;
methods of express-
ing variability within the
rankings; oral health
indicators; mental health
indicators; improved
health disparities;
improved cost measures;
quality of care measures;
and international bench-
marking. (Some of these
measures are included
in the expanded detail
of each states health
prole at http://www.americashealthrankings.org/
SfafeRanklng buf are nof lncluded ln calculaflng
the overall state rank.)
The committee also stresses the importance of
focusing on determinants, as improving these mea-
sures can improve the healthiness of each state
and the nation. The overall ranks for combined
determinants as well as outcomes are presented in
each state snapshot.
The methodology review group represents a
variety of stakeholders, including representatives
from state health departments and the Centers
for Disease Control and Prevention, members of
APHA, as well as experts from many academic
disciplines.
The committee
stresses the
importance of
focusing on
determinants.
Anna Schenck, Ph.D., M.S.P.H., Chair
Director, Public Health Leadership Program
UNC Gillings School of Global Public Health
University of North Carolina at Chapel Hill
Dennis P. Andrulis, Ph.D., M.P.H.
Senior Research Scientist
Texas Health Institute
Jamie Bartram, Ph.D.
Professor and Director of Global Water Institute
Bridget Booske Catlin, Ph.D., M.H.S.A.
Senior Scientist and MATCH Group Director
University of Wisconsin Population Health Institute
Director, County Health Rankings & Roadmaps
Andy Coburn, M.D.
Professor and Director, Institute for Health Policy
University of Southern Maine
Leah Devlin, D.D.S., M.P.H.
Professor of the Practice, Health Policy
and Management
Marisa Domino, Ph.D.
Professor, Health Policy and Management
Paul Erwin, M.D., M.P.H.
Director, Center for Public Health Policy
and Research
University of Tennessee
Jonathan Fielding, M.D., M.P.H., M.B.A., M.A.
Professor of Health Services and Pediatrics
UCLA School of Public Health
Director of Public Health and Health Ofcer,
Los Angeles County
Marthe Gold, M.D.
Logan Professor and Chair
Department of Community Health
CUNY Medical School
Sherman A. James, Ph.D., F.A.H.A.
Susan B. King Professor of Public Policy
Professor of Sociology,
Community and Family Medicine and
African and African American Studies
Duke University
Glen P. Mays, Ph.D., M.P.H.
F. Douglas Scutcheld Endowed Professor
Health Services and Systems Research
University of Kentucky College of Public Health
Matthew T. McKenna, M.D., M.P.H.
Medical Director
Fulton County Department of Health Services
Anne-Marie Meyer, Ph.D.
Facilities Director
Integrated Cancer Information and
Surveillance System
UNC Lineberger Comprehensive Cancer Center
Patrick Remington, M.D., M.P.H.
Associate Dean for Public Health
University of Wisconsin School of Medicine
and Public Health
Health Sciences Learning Center
Thomas C. Ricketts, Ph.D., M.P.H.
Professor of Health Policy and Administration
and Social Medicine
Leiyu Shi, Ph.D.
Professor
Department of Health Policy and Management
Co-Director, Primary Care Policy Center
for the Underserved
Johns Hopkins University School of Public Health
Steven Teutsch, M.D., M.P.H.
Chief Science Ofcer
Los Angeles County Department of Public Health
Director and Health Ofcer
Tom Eckstein, M.B.A.
Principal
Arundel Street Consulting, Inc.
Scientic Advisory Committee members include:
Findings
Findings
2012 Edition Results
2012 Edition shows

Vermont at the top of the list of healthiest states
again this year. The state steadily rose in the
rankings over the last 14 years from a ranking of
17th in 1998 to rst, where it has remained for 6
printed editions. Hawaii is ranked second this year,
an improvement from ranking fourth in the 2011
Edition and fth in the 2009 and 2010 Editions.
Hawaii has ranked in the top 6 states every year
of the index. New Hampshire is third, followed
by Massachusetts and Minnesota. Mississippi and
Louisiana tie for 49th as the least healthy states.
Arkansas, West Virginia, and South Carolina com-
plete the bottom 5 states.
Vermont ascended from 20th in 1990 and 1991
to the top position with sustained improvement
in the last decade. Vermonts strengths include its
number one position for all health determinants
combined, which includes ranking in the top 10
states for a high rate of high school graduation, a
low violent crime rate, a low incidence of infec-
tious disease, a low prevalence of low birthweight
infants, high per capita public health funding,
a low rate of uninsured population, and ready
availability of primary care physicians. Vermonts
challenges are a high prevalence of binge drinking
at 18.5 percent of the adult population, a moder-
ate occupational fatalities rate at 3.9 deaths per
100,000 workers, and a median cancer death rate
at 185.0 deaths per 100,000 population. For fur-
ther details, see Vermonts state snapshot on page
103 or visit www.americashealthrankings.org/VT.
Mississippi and Louisiana are tied for 49th and
rank last this year. These 2 states have been in the
bottom 3 states since the 1990 Edition.
Mississippi ranks well for a low prevalence
of binge drinking and a low violent crime rate.
It ranks in the bottom 5 states on 12 of the 24
measures including a high prevalence of obesity,
a high prevalence of a sedentary lifestyle, a low
high school graduation rate, limited availability
of primary care physicians, a high prevalence of
low birthweight infants, and a high prevalence
of diabetes. Mississippi ranks 49th for all health
determinants combined, so its overall ranking is
unlikely to change signicantly in the near future.
For further details, see Mississippis state snapshot
on page 82 or visit www.americashealthrankings.
org/MS.
Louisiana ranks well for a low prevalence of
binge drinking and a high rate of childhood immu-
nizations. It ranks in the bottom 5 states on 13 of
the 24 measures including a high prevalence of
obesity, a high rate of children in poverty, a high
prevalence of low birthweight infants, a high prev-
alence of diabetes, and
a high rate of cardiovas-
cular and cancer deaths.
For further details, see
Louisianas state snapshot
on page 76 or visit www.
americashealthrankings.
org/LA.
Table 1 (page 14) lists
the score and ranking for
each of the 50 states.
Scores presented in the tables indicate the
weighted number of standard deviation units a
state is above or below the national norm. For
example, Vermont, with a score of 1.196, is slightly
more than one standard deviation unit above the
national norm. Mississippi and Louisiana, with
scores of -0.938, are almost one standard devia-
tion below the national average. When comparing
states from year to year, differences in score are
more important than changes in ranking.
For a state to improve the health of its
population, efforts must focus on changing the
determinants of health. If a state is signicantly
better in its score for determinants than its score
for outcomes, it will likely improve its overall
health ranking in the future. Conversely, if a state
is worse in its score for determinants than its score
for outcomes, its overall health ranking will likely
decline over time.
Table 2 (page 15) presents the overall score for
the determinants, outcomes, and their implications
for the future. If the current trend is positive, the
future overall ranking is more likely to increase; if it
is neutral, the future overall ranking will probably
stay the same; or if it is negative, the future overall
ranking is more likely to decline.
Findings
Each state has
its unique set of
strengths and
challenges that
affect its health.
1 4 www. amer i c as heal t hr anki ngs . or g
Findings
Table 1
Overall Rankings,
2012 Edition
RANK STATE SCORE* RANK STATE SCORE*
ALPHABETICAL BY STATE RANK ORDER
*Scores presented in this
table indicate the weighted
number of standard
deviations a state is above
or below the national norm.
45
28
25
48
22
11
6
31
34
36
2
17
30
41
20
24
44
49
9
19
4
37
5
49
42
29
15
38
3
8
32
18
33
12
35
43
13
26
10
46
27
39
40
7
1
21
13
47
16
23
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
-0.521
0.083
0.139
-0.717
0.262
0.549
0.820
-0.063
-0.138
-0.261
0.977
0.425
-0.059
-0.341
0.299
0.152
-0.470
-0.938
0.621
0.336
0.879
-0.269
0.821
-0.938
-0.403
0.037
0.514
-0.280
0.897
0.643
-0.069
0.398
-0.105
0.543
-0.245
-0.464
0.527
0.104
0.587
-0.535
0.091
-0.317
-0.328
0.805
1.196
0.268
0.527
-0.655
0.486
0.236
1
2
3
4
5
6
7
8
9
10
11
11
13
13
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
49
Vermont
Hawaii
New Hampshire
Massachusetts
Minnesota
Connecticut
Utah
New Jersey
Maine
Rhode Island
Colorado
North Dakota
Oregon
Washington
Nebraska
Wisconsin
Idaho
New York
Maryland
Iowa
Virginia
California
Wyoming
Kansas
Arizona
Pennsylvania
South Dakota
Alaska
Montana
Illinois
Delaware
New Mexico
North Carolina
Florida
Ohio
Georgia
Michigan
Nevada
Tennessee
Texas
Indiana
Missouri
Oklahoma
Kentucky
Alabama
South Carolina
West Virginia
Arkansas
Louisiana
Mississippi
1.196
0.977
0.897
0.879
0.821
0.820
0.805
0.643
0.621
0.587
0.549
0.543
0.527
0.527
0.514
0.486
0.425
0.398
0.336
0.299
0.268
0.262
0.236
0.152
0.139
0.104
0.091
0.083
0.037
-0.059
-0.063
-0.069
-0.105
-0.138
-0.245
-0.261
-0.269
-0.280
-0.317
-0.328
-0.341
-0.403
-0.464
-0.470
-0.521
-0.535
-0.655
-0.717
-0.938
-0.938
Table 2
Determinants and
Outcomes, 2012 Edition
A M E R I C A S H E A L T H R A N K I N G S 1 5
STATE SCORE FOR ALL SCORE FOR ALL INFLUENCE ON FUTURE
DETERMINANTS* OUTCOMES* OVERALL RANK
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
-0.259
0.128
0.056
-0.482
0.12
0.386
0.608
-0.078
-0.015
-0.182
0.682
0.294
-0.083
-0.284
0.059
0.094
-0.255
-0.661
0.506
0.331
0.62
-0.226
0.514
-0.63
-0.317
0.005
0.31
-0.247
0.646
0.449
-0.117
0.253
-0.036
0.427
-0.177
-0.264
0.392
0.1
0.467
-0.402
0.136
-0.146
-0.364
0.59
0.947
0.251
0.37
-0.385
0.326
0.155
-0.262
-0.045
0.083
-0.235
0.143
0.163
0.212
0.015
-0.123
-0.08
0.295
0.131
0.024
-0.057
0.241
0.058
-0.215
-0.277
0.116
0.005
0.259
-0.043
0.307
-0.308
-0.086
0.032
0.204
-0.033
0.251
0.195
0.048
0.145
-0.07
0.116
-0.068
-0.2
0.134
0.005
0.12
-0.132
-0.046
-0.171
0.036
0.215
0.249
0.017
0.157
-0.271
0.16
0.081
Neutral
Neutral
Neutral
Negative
Neutral
Positive
Positive
Neutral
Neutral
Neutral
Positive
Neutral
Neutral
Negative
Neutral
Neutral
Neutral
Negative
Positive
Positive
Positive
Neutral
Positive
Negative
Negative
Neutral
Neutral
Negative
Positive
Positive
Neutral
Neutral
Neutral
Positive
Neutral
Neutral
Positive
Neutral
Positive
Negative
Neutral
Neutral
Negative
Positive
Positive
Positive
Positive
Neutral
Neutral
Neutral
*Scores presented in this
table indicate the weighted
number of standard
deviations a state is above or
below the national norm.
After 22 years of viewing changes in population
health over time, Americas Health Rankings
.
has
established a new baseline from which all future
changes will be compared. One of the underly-
ing data sources for Americas Health Rankings
underwent signicant changes

in the last year and required this
new baseline to be established.
The new baseline is not compa-
rable to prior trend information
shown in prior years.
CDCs Behavioral Risk Factor
Surveillance System (BRFSS), a
telephone survey of nearly half
a million households and the
source for 7 of the measures
in the overall index, intro-
duced 2 major changes in their most recent data
release to improve the estimates of behaviors in
a states population. These changes altered both
the household selection process and the analysis
methodology to better reect the growth of cell-
phone only households and the increasing diversity
of households within a state. This has caused the
reported prevalence of many of the behavior mea-
sures, such as smoking, obesity, binge drinking,
and diabetes, to be reported as higher this year
than last year. This change may or may not reect
an actual change in the behavior being measured,
but it does represent a dramatic improvement
in how well the estimates actually measure the
behaviors. The new estimates are superior to esti-
mates collected in prior years and set the standard
going forward in the new baseline.
Some of the individual components of the index
continue to be comparable over time and their
changes are shown in Table 3 (page 17). Five of
these items are discussed in greater detail here.
Potentially preventable hospitalizations (hospi-
tal admissions that may be preventable with high
quality primary and preventive care) have declined
over the last 11 years from 82.5 to 66.6 admis-
sions per 1,000 Medicare enrollees (Graph 1 on
This edition
establishes a
new baseline
for the nations
health.
page 18). Preventable hospitalizations reect how
efciently a population uses the various health care
delivery options for necessary care. Hospital care
is expensive and makes up the largest component
of health care spending in the U.S., totaling over
$750 billion.
1
Preventable hospitalizations often
occur as a result of a failure to treat conditions
early in an outpatient setting due to limited avail-
ability.
2
These discharges are also highly correlated
with general admissions and reect the tendency
for a population to overuse the hospital setting as
a site for care. Preventable hospitalizations place
a nancial burden on heath care systems as they
could have been avoided with earlier, less costly
interventions. Preventable hospitalizations are
more common in those who are uninsured, which
often leads to large unpaid medical bills.
3
Potentially preventable hospitalizations are a sig-
nicant issue with regard to both quality and cost.
The Agency for Healthcare Research and Quality
(AHRQ) reports that in the year 2000, nearly
5 million admissions to U.S. hospitals involved
treatment for one or more potentially prevent-
able conditions, with a resulting cost of more
than $26.5 billion. Furthermore, AHRQ states that
While some hospitalizations were likely inevitable,
many might have been prevented if individuals had
received high quality primary and preventive care.
Identifying and reducing such avoidable hospital-
izations could help alleviate the economic burden
placed on the U.S. health care system. Assuming
an average cost of $5,300 per admission, even a 5
percent decrease in the rate of potentially avoid-
able hospitalizations could result in a cost savings
of more than $1.3 billion.
4
1. The Kaiser Family Foundation. Trends in Health Care Costs and
Spending. 2009;7692-02.
2. Billings J. Recent ndings on preventable hospitalizations.
Health Aff. 1996;15(3):239.
3. Weissman JS. Rates of avoidable hospitalization by insurance
status in Massachusetts and Maryland. JAMA. 1992;268(17):2388.
4. Agency for Healthcare Research and Quality, US Department
of Health and Human Services, http://www.ahrq.gov/data/hcup/
factbk5/factbk5a.htm. Accessed October 27, 2011.
Table 3
National Successes
and Challenges,
2012 Edition
SUCCESSES
Preventable Hospitalizations Preventable hospitalizations continue to decline. In 2001, there were 82.5 discharges; in
2012, there were 66.6 discharges per 1,000 Medicare enrollees.
Occupational Fatalities Occupational fatalities have declined slightly in the last 5 years from 5.3 deaths in 2007 to
4.1 deaths per 100,000 workers in the 2012 Edition. This is essentially equal to the 2011
Edition rate of 4.0 deaths per 100,000 workers. Rates are the lowest in 23 years.
Air Pollution The average amount of ne particulate in the air continues to decline from 13.2 micro-
grams in 2003 to 10.5 micrograms per cubic meter in 2012.
Infectious Disease Infectious disease has dropped from 19.7 cases in 1998 to 12.4 cases per 100,000
population in the 2012 Edition. However, the incidence remains above the rate of 9.0 cases
achieved in 2009 and 2010 and 10.3 cases per 100,000 populaton in the 2011 Edition.
Infant Mortality The infant mortality rate decreased 36 percent from 10.2 deaths in 1990 to 6.5 deaths per
1,000 live births in 2012. Compared to the 1990s, improvements have slowed dramatically
in the last 12 years.
Premature Death Since 1990, there has been an 18 percent decline from 8,716 years of potential life lost
before age 75 per 100,000 population to 7,151 years of potential life lost before age 75
per 100,000 population in 2012. Premature deaths, like several other metrics, have leveled
off in the last decade compared to gains in the 1990s.
Cardiovascular Deaths Since 1990, cardiovascular deaths have declined 35 percent, from 405.1 deaths in 1990
to 264.9 deaths per 100,000 populaton in the 2012 Edition. This continues a relatively
constant improvement of 2 percent to 3 percent each year.
Cancer Deaths Cancer deaths declined 8 percent from 197.5 deaths in 1990 to 182.5 deaths per
100,000 populaton in the 2012 Edition. This continues to show a more rapid improvement
in the last few years than earlier in the 2000s.
High School Graduation At only 75.5 percent of ninth graders receiving a diploma within 4 years, high school
graduation is still a challenge. However, it is on a trend of slowly increasing from 71.7
percent in 2004.
Violent Crime At 404 offenses per 100,000 population, violent crime is 34 percent lower than in 1990
and 47 percent lower than its peak in 1993.
CHALLENGES
Children in Poverty The percentage of children in poverty, at 21.4 percent of persons under age 18, remains
above 20 percent for the third straight year. This is far above the 23-year low of 15.8
percent in the 2002 Edition.
Lack of Health Insurance The rate of uninsured population increased 15 percent from 13.9 percent ten years ago to
16.0 percent in 2012. The rate of uninsured population has remained relatively stable for
the last three years.
Immunization Coverage Immunization coverage nationwide remains stagnant at 90.3 percent of children ages 19 to
35 months receiving key vaccinations.
Low Birthweight In the last 20 years, the prevalence of low birthweight infants has increased from 7.0
percent to 8.1 percent nationwide. The good news is that it appears to have leveled off in
the most recent six years, and the trend may start to reverse in the future.
MEASURE CHANGES
Graph 1
Preventable
Hospitalizations
Since 2001
Graph 2
Cardiovascular
Deaths
Since 2001
N
U
M
B
E
R

P
E
R

1
,
0
0
0

M
E
D
I
C
A
R
E

E
N
R
O
L
L
E
E
S
2001 02 03 04 05 06 07 08 09 10 11 12
90
80
70
60
50
40
30
20
10
0
D
E
A
T
H
S

P
E
R

1
0
0
,
0
0
0

P
O
P
U
L
A
T
I
O
N
2001 02 03 04 05 06 07 08 09 10 11 12
450
400
350
300
250
200
150
100
50
0
Preventable hospitalizations are also a window
into the disparities that exist in the health care
delivery system. In a study of 2003 data by Russo
et al.,
5
racial and ethnic disparities existed in the
rates of preventable hospitalizations, with blacks
generally having the highest rates and Hispanics
the second highest rates. In particular, dispari-
ties were greatest for hospitalizations related to
chronic health conditions such as diabetes, hyper-
tension, and asthma. Compared with non-Hispanic
whites, rates of admission for these conditions
were about 3 to 5 times greater among blacks
and approximately 2 to 3 times greater among
Hispanics.
Deaths from cardiovascular disease have consis-
tently declined by 2 percent to 3 percent per year
for the last decade (Graph 2), a notable accom-
plishment of the health care system. This decline
is in spite of increasing risk factors such as obesity,
high cholesterol, and high blood pressure.
Cardiovascular disease accounts for 17 percent
of medical spending, 30 percent of Medicare
spending, and totals nearly $150 billion annually.
6
The difcult economic climate increases the
challenge of maintaining a healthy population.
Graph 4 (page 19) depicts the continuing high
percentage of children in poverty, increasing from
16.1 percent of children in the 2001 Edition to
21.4 percent of children in the 2012 Edition. The
historic low of 15.8 percent of persons under age
18 was recorded in the 2002 Edition.
Life expectancy at birth measures the expected number
of years that a newborn child will live. It is based upon the
age-specic mortality rates for the whole population at the
time of birth.
Between 1900 and 2009, the life expectancy at birth
increased by 31.2 years from 47.3 years in 1900 to 78.5
years of life in 2009. From 2000 to 2009, it increased by 1.7
years from 76.8 years of life in 2000 to 78.5 years in 2009.
In 1900, the life expectancy at birth for blacks was 33.0
years, 14.6 years less than whites. This gap declined to 5.5
years in 2000 and 4.3 years in 2009. In 1990, the life expec-
tancy at birth for women was 48.3 years, two years longer
than men. This gap between life expectancy at birth for
males and females reached a maximum of 7.8 years in 1975
and has now declined to 4.9 years in 2009.
Graph 3
Life Expectancy
at Birth
Source: National
Center for Health
Statistics. Health,
United States, 2011:
With Special Feature
on Socioeconomic
Status and Health.
Hyattsville, MD. 2012.
Y
E
A
R
S

O
F
L
I
F
E
1900 1920 1940 1960 1980 2000
90
80
70
60
50
40
30
20
10
0
Life Expectancy in the United States
Graph 4
Children in
Poverty
Since 2001
Graph 5
Infant
Mortality
Since 1990
Graph 6
Low
Birthweight
Infants
Since 1993
D
E
A
T
H
S

P
E
R

1
,
0
0
0

L
I
V
E

B
I
R
T
H
S
1990 92 94 96 98 00 02 04 06 08 10 12
12
10
8
6
4
2
0
P
E
R
C
E
N
T

O
F

P
E
R
S
O
N
S

U
N
D
E
R

A
G
E

1
8
2001 02 03 04 05 06 07 08 09 10 11 12
25
20
15
10
5
0
Children in poverty is an indication of the lack
of access to health care, including preventive
care, for this vulnerable population.
Infant mortality improved signicantly in the
1990s but has largely stagnated between 6.5
and 7.0 deaths per 1,000 live births for the last
ten years (Graph 5). The nations overall infant
mortality rate is consistently higher than other
developed countries, and signicant racial and
ethnic disparities exist.
7
For the last six years, between 8.1 percent
and 8.3 percent of all infants are born with a
low birthweight (<2,500 grams or 5 pounds,
8 ounces). This is up from 7.0 percent in 1993
(Graph 6).
Babies born with low birthweight are often
born preterm or have inadequate growth for
other reasons. Low birthweight may occur as
a result of inadequate clinical care during the
prenatal period. Through regular clinical visits,
the health of the mother can be assessed, health
risks can be identied, and steps can be taken
to improve the mothers health. Low birthweight
is associated with many characteristics of the
mother such as smoking status, nutritional status
and psychosocial problems.
P
E
R
C
E
N
T

O
F

L
I
V
E

B
I
R
T
H
S
1990 92 94 96 98 00 02 04 06 08 10 12
9
8
7
6
5
4
3
2
1
0
5. Russo CA, Andrews RM, Coffey RM. Healthcare Cost and
Utilization Project (HCUP) Statistical Brief #10. Rockville, MD:
http://www.ncbi.nlm.nih.gov/books/NBK63497/#sb10.s2. 2006.
Accessed on Oct 27, 2011.
6. Trogdon J T G, Finkelstein EA, Nwaise IA, Tangka TT FK,
Orenstein D. The economic burden of chronic cardiovascular
disease for major insurers. Health Promotion Practice. 8.3
(2007):234-42. Print.
7. MacDorman MF, Mathews FF TJ. Recent Trends in Infant
Mortality in the United States. Hyattsville, MD: US Dept. of
Health and Human Services, Centers for Disease Control and
Prevention, National Center for Health Statistics. 2008.
For a population to be healthy, it must minimize
health disparities among segments of the popula-
tion, including differences that occur by gender, race
or ethnicity, education, income, disability, geographic
location, or sexual orientation.
The statewide measures used in Americas Health
Rankings
reect the condition of the average

resident and can mask differences within the state.
When the measures are examined by race, gender,
geographic location, and/or economic status, star-
tling differences can exist within a state.
The National Healthcare Disparities Report (http://
www.ahrq.gov/qual/nhdr11/nhdr11.pdf), released
each year by the Agency for Healthcare Research and
Quality, highlights disparities in healthcare delivery at a
national level.
8
The report analyzes numerous measures
and indicates that disparities exist for many groups,
including women, children, the elderly, rural residents,
and among racial and socio-economic groups. The
report also indicates that such disparities affect all
aspects of health and health care delivery, including
preventive care, acute care, and chronic disease man-
agement. They also affect many health care delivery
locations including primary care, home health care,
hospice, emergency care, hospitals, and nursing homes.
The report highlights several key themes this year.
Healfh care quallfy and access are subopflmal,
especially for minority and low-income groups.
Even fhough overall quallfy ls lmprovlng, access
and disparities are not improving.
rgenf affenflon ls warranfed wlfh respecf fo cer-
tain services, geographic areas, and populations,
such as:
o Cancer screening and management of diabetes.
o States in the central part of the country.
o Residents of inner city and rural areas.
o Disparities in preventive services and access to care.
All eight national priority areas (1) Palliative and
End-ol-Llle Care, (2) Faflenf and Famlly Engagemenf,
(3) Population Health, (4) Safety, (5) Access, (6) Care
Coordination, (7) Overuse, and (8) Health System
Infrastructure showed disparities related to race,
ethnicity, and socioeconomic status. While each
state has unique issues that contribute to disparities,
states that have been successful in reducing dispari-
ties in health indicators while retaining high overall
health can serve as models for other states.
Llle expecfancy has been shown fo vary by bofh
race and educational level, and these differences
are expanding over time. This has led to at least two
Americas in terms of life expectancy dened by
racial-group membership and education level.
Kulkarni et. al.
9
further highlight the disparities that
exist by calculating the extensive differences in life
expectancy by race and gender in counties throughout
fhe nlfed Sfafes.
10
They showed that while overall
.S. llle expecfancy lor men and women averaged
75. and 80.8 years respecflvely ln 2007, counfy-by-
county life expectancy ranged from 65.9 to 81.1 years
for men and 73.5 to 86.0 years for women. If viewed
from a racial disparity perspective, life expectancy at
blrfh ranges lrom 5.4 fo 77.2 years lor black men and
. fo 82. years lor black women.
For both men and women, life expectancies for
whites consistently exceed life expectancies for blacks.
Policies and programs to address this disparity should
look at both the magnitude of disparity at the state
level and the number of people affected.
11
contains an explicit
metric for disparitiesGeographic Disparity. This
indicator reects the range of age-adjusted mortality
rates that exist within a state at the county level. State
data is available at http://www.americashealthrankings.
org/All/Disparity. This overall disparity metric provides
a broad view of the challenges facing a state.
Disparity is also present among the behavior of the
race/ethnic groups within states. Tables 4 to 6 (pages
2123) show varlaflons ln fhe prevalence ol smoklng,
sedentary lifestyle, and obesity by race/ethnicity and
sfafe. These fables, based upon 200 and 2010 BRFSS
data, illustrate that disparities differ by state. In some
states there are large differences between racial/ethnic
groups, whereas in other states, the differences are
much less pronounced.
Table 7 (page 24) shows fhe varlaflon ln lnlanf mor-
tality rate by race group. Infant mortality varies greatly
by race group and state.
This type of analysis, especially when expanded to
encompass a broader range of social, economic, and
health indicators, allows communities, their organiza-
tions, and public health ofcials to target programs to
address the biggest areas of concern.
These fables show fhe dlsparlfy ln recenf dafa. Each
state prole, available at www.americashealthrankings.
org/Downloads, shows the trends in smoking,
sedentary lifestyle, obesity, and infant mortality rate
over the past 8 years. A le containing this data is also
available at this web address.
Health Disparities
Health Disparities within States
8. AHRQ. National Healthcare Disparities Report, 2011, AHRQ publication no. 12-0006. March 2012.
9. Kulkarni SC, Levin-Rector A, Ezzati M, Murray CJL. Falling behind: life expectancy in US counties from 2000-2007 in an international con-
text. Population Health Metrics. 2011, 9:16, http://www.pophealthmetrics.com/content/9/1/16.
10. Olshansky SJ, Antonucci T, Berkman L, et al. Differences in life expectancy due to race and educational differences are widening, and
many may not catch up [disparities] Health Aff. 2012;31(8):1803-1813. http://content.healthaffairs.org. doi: 10.1377/hlthaff.2011.0746.
11. Bharmal N, Tseng C, Kaplan R, Wong MD. State-level variations in racial disparities in life expectancy. Health Services Research.
2011;46(5). http://dx.doi.org/10.1111%2F%28ISSN%291475-6773. doi: 10.1111/j.1475-6773.2011.01345.x.
Table 4
Prevalence of
Smoking by Race/
Ethnicity and State
(percent of adult
population),
2012 Edition
Source: Centers for Disease
Control and Prevention
(CDC). Behavioral Risk Factor
Surveillance Survey Data,
Atlanta, GA. 2009-2010. Blank
indicates data is not available
for this subgroup.
Note: Differences between
groups may be more or less
than shown because the
reliability of self-report data
varies by ethnic and racial
groups.
22.0% 21.7% 31.9% 35.0%
17.5% 26.1% 37.9%
15.5% 13.6% 16.1% 9.0% 16.5%
21.9% 22.7% 16.8%
12.6% 17.8% 12.2% 6.5% 18.0% 27.5%
15.7% 17.1% 18.7% 12.4% 23.9%
14.1% 16.9% 14.2% 11.6%
18.3% 15.5% 23.3% 1.7%
18.5% 15.8% 11.5% 6.5% 37.3%
18.8% 15.7% 13.6% 7.6%
14.1% 21.4% 10.1% 23.1%
15.9% 14.2% 31.7%
17.0% 22.2% 17.8% 7.8%
21.4% 30.8% 20.1% 42.3%
16.4% 27.1% 15.4%
16.9% 23.6% 17.1% 7.8% 43.4%
24.9% 27.3% 25.2% 45.5%
22.4% 21.1% 19.1% 27.6%
17.4% 25.1% 46.6%
15.2% 17.1% 10.4% 7.7%
14.4% 16.8% 14.7% 6.1% 37.1%
18.7% 21.1% 21.6% 10.6% 28.6%
15.4% 21.2% 17.1% 2.9% 50.7%
22.7% 24.1% 18.8%
21.5% 25.2% 20.5%
15.5% 29.4% 45.8%
16.3% 22.6% 16.5% 48.4%
21.7% 22.3% 19.0% 20.9% 24.1%
15.9% 17.4%
16.0% 17.0% 13.7% 7.3% 10.5%
15.9% 23.6% 20.0% 14.9% 20.9%
17.0% 16.9% 16.3% 9.9%
20.0% 20.9% 13.9% 16.0% 34.0%
16.1% 32.8% 47.2%
21.2% 22.8% 25.0% 4.4% 52.5%
23.3% 31.9% 20.7% 9.1% 31.6%
15.3% 16.3%
18.6% 27.3% 16.1% 7.2%
15.4% 13.5% 11.6% 5.7%
20.6% 19.5% 17.2% 45.4%
14.4% 17.7% 50.5%
21.7% 19.8% 16.4%
17.8% 16.9% 15.5% 9.9% 32.3%
9.2% 11.2% 7.7% 20.3%
15.7% 17.8%
17.9% 18.0% 27.4% 11.4%
14.9% 20.7% 11.7% 4.9% 18.6% 29.2%
26.3% 21.1% 22.8%
17.9% 25.5% 29.6% 30.3%
18.6% 24.2% 50.6%
17.8% 19.6% 14.4% 8.5% 20.7% 33.0%
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
United States
NON-
HISPANIC
WHITE
NON-
HISPANIC
BLACK HISPANIC
NON-
HISPANIC
ASIAN
NON-
HISPANIC
HAWAIIAN
/ PACIFIC
ISLANDER
NON-
HISPANIC
AMERICAN
INDIAN OR
ALASKAN
NATIVE
Table 5
Prevalence of
Sedentary Lifestyle
by Race/Ethnicity
and State (percent
of adult population),
2012 Edition
Source: Centers for Disease
Control and Prevention
(CDC). Behavioral Risk
Factor Surveillance Survey
Data, Atlanta, GA.
2009-2010. Blank indicates
data is not available for
this subgroup.
groups may be more or less
than shown because the
reliability of self-report data
varies by ethnic and
racial groups.
NON-
HISPANIC
WHITE
NON-
HISPANIC
BLACK HISPANIC
NON-
HISPANIC
ASIAN
NON-
HISPANIC
HAWAIIAN
/ PACIFIC
ISLANDER
NON-
HISPANIC
AMERICAN
INDIAN OR
ALASKAN
NATIVE
Alabama 29.4% 36.1% 29.2% 27.0%
Alaska 19.8% 23.1% 28.8%
Arizona 19.2% 19.8% 23.9% 5.1% 18.2%
Arkansas 29.4% 31.7% 29.9%
California 16.1% 26.4% 27.0% 19.3% 19.1% 28.1%
Colorado 14.8% 26.9% 27.7% 18.8% 27.7%
Connecticut 19.9% 27.4% 27.5% 28.1%
Delaware 20.7% 32.1% 30.4% 23.2%
Florida 22.2% 28.9% 29.9% 19.5% 23.8%
Georgia 22.6% 28.8% 30.1% 25.8%
Hawaii 14.8% 21.4% 23.0% 26.4%
Idaho 19.2% 35.6% 27.9%
Illinois 23.3% 29.5% 27.2% 23.3%
Indiana 26.2% 32.5% 28.0% 32.9%
Iowa 23.8% 32.7% 34.3%
Kansas 22.8% 26.5% 34.1% 19.0% 29.6%
Kentucky 29.6% 30.9% 26.2% 27.8%
Louisiana 26.4% 35.9% 25.1% 35.1%
Maine 21.8% 16.7% 33.1%
Maryland 20.7% 29.1% 28.6% 23.9%
Massachusetts 18.6% 26.2% 35.5% 21.5% 29.8%
Michigan 22.7% 29.6% 23.9% 17.7% 23.8%
Minnesota 16.8% 29.4% 24.6% 13.3% 17.9%
Mississippi 30.3% 37.2% 27.3%
Missouri 25.7% 37.5% 34.6%
Montana 21.1% 23.7% 29.9%
Nebraska 23.2% 40.8% 35.6% 25.7%
Nevada 22.4% 25.5% 27.5% 21.2% 21.3%
New Hampshire 20.7% 22.5%
New Jersey 22.7% 31.1% 36.9% 23.7% 32.7%
New Mexico 18.7% 23.5% 26.3% 14.0% 24.4%
New York 22.7% 29.3% 30.6% 21.1%
North Carolina 24.4% 32.6% 26.7% 25.4% 31.2%
North Dakota 25.0% 49.5% 28.3%
Ohio 25.3% 35.0% 27.6% 20.1% 36.5%
Oklahoma 29.7% 36.4% 35.7% 27.8% 30.2%
Oregon 17.3% 21.3%
Pennsylvania 24.5% 31.9% 33.6% 27.5%
Rhode Island 23.3% 35.2% 31.2% 31.7%
South Carolina 24.9% 30.7% 35.6% 38.9%
South Dakota 24.0% 20.6% 31.8%
Tennessee 29.5% 33.6% 39.6%
Texas 23.1% 30.7% 33.7% 20.6% 24.2%
Utah 16.2% 32.6% 24.1% 22.2%
Vermont 18.9% 17.9%
Virginia 20.7% 30.8% 30.7% 20.3%
Washington 17.7% 24.1% 31.4% 19.0% 16.1% 22.6%
West Virginia 32.9% 43.2% 36.4%
Wisconsin 21.6% 35.1% 26.0% 30.0%
Wyoming 22.3% 22.9% 18.2%
United States 22.4% 30.9% 30.6% 21.1% 22.6% 28.0%
Health Disparities
Table 6
Prevalence of
Obesity by Race/
Ethnicity and State
(percent of adult
population),
2012 Edition
NON-
HISPANIC
WHITE
NON-
HISPANIC
BLACK HISPANIC
NON-
HISPANIC
ASIAN
NON-
HISPANIC
HAWAIIAN
/ PACIFIC
ISLANDER
NON-
HISPANIC
AMERICAN
INDIAN OR
ALASKAN
NATIVE
28.8% 43.1% 31.1% 33.5%
Alaska 23.7% 33.5% 30.8%
Arizona 24.1% 30.4% 31.0% 8.0% 41.9%
Arkansas 30.4% 43.2% 31.0%
California 21.6% 37.7% 31.1% 9.6% 21.6% 31.5%
Colorado 18.7% 28.5% 24.5% 7.6% 31.2%
Connecticut 21.0% 41.4% 28.6% 7.0%
Delaware 26.4% 41.1% 28.9%
Florida 24.7% 39.1% 29.1% 12.3% 29.2%
Georgia 26.1% 37.6% 37.6% 7.0%
Hawaii 19.4% 25.7% 13.4% 58.5%
Idaho 25.3% 33.3% 40.3%
Illinois 26.0% 41.0% 31.1% 9.7%
Indiana 29.7% 37.2% 32.5% 33.0%
Iowa 28.9% 31.0% 29.4%
Kansas 28.9% 39.4% 35.4% 5.5% 34.9%
Kentucky 31.8% 42.5% 38.7% 25.6%
Louisiana 29.3% 41.6% 28.9% 39.2%
Maine 27.0% 20.9% 28.9%
Maryland 24.4% 36.7% 29.7% 7.5%
Massachusetts 22.1% 31.5% 29.9% 9.9% 24.9%
Michigan 29.2% 42.1% 38.8% 8.4% 41.7%
Minnesota 25.1% 26.6% 27.9% 19.2% 37.6%
Mississippi 30.9% 43.2% 33.4%
Missouri 30.1% 39.3% 29.1%
Montana 22.7% 23.8% 40.7%
Nebraska 27.0% 39.6% 35.4% 46.6%
Nevada 24.4% 30.4% 23.4% 16.6% 35.2%
New Hampshire 26.2% 21.0%
New Jersey 23.3% 36.0% 27.8% 8.1% 27.5%
New Mexico 20.6% 26.9% 30.7% 10.0% 39.1%
New York 23.8% 32.2% 26.8% 9.1%
North Carolina 26.5% 42.9% 24.8% 6.5% 33.9%
North Dakota 27.5% 40.8% 45.3%
Ohio 28.7% 42.5% 33.1% 8.5% 36.2%
Oklahoma 29.9% 42.9% 29.7% 5.7% 41.1%
Oregon 25.2% 28.3%
Pennsylvania 28.0% 38.9% 35.2% 4.7%
Rhode Island 24.7% 35.7% 31.4% 12.9%
South Carolina 27.8% 39.9% 39.9% 31.0%
South Dakota 28.3% 32.2% 39.8%
Tennessee 31.1% 42.4% 20.0%
Texas 26.9% 38.4% 37.8% 9.3% 36.8%
Utah 23.1% 29.4% 7.8% 31.2%
Vermont 23.6% 19.0%
Virginia 25.1% 38.1% 24.1% 6.0%
Washington 26.4% 35.7% 31.8% 6.1% 27.1% 42.2%
West Virginia 32.1% 42.0% 28.3%
Wisconsin 27.2% 49.4% 19.3% 43.4%
Wyoming 24.6% 32.9% 40.9%
United States 26.1% 38.8% 31.0% 9.4% 26.3% 35.8%
Centers for Disease Control and
Prevention (CDC). Behavioral
Risk Factor Surveillance Survey
Data, Atlanta, GA. 2009-2010.
Blank indicates data is not
available for this subgroup.
groups may be more or less than
shown because the reliability of
self-report data varies by ethnic
and racial groups.
Table 7
Infant Mortality Rate
by Race (deaths per
1,000 live births),
2012 Edition
Alabama 6.2 13.2
Alaska 5.2
Arizona 5.3 16.9
Arkansas 6.3 12.6
California 4.7 11.2
Colorado 5.7 16.6
Connecticut 4.6 11.9
Delaware 4.6 17.0
Florida 5.2 12.2
Georgia 5.2 11.6
Hawaii 5.1
Idaho 5.4
Illinois 5.6 13.7
Indiana 6.7 16.7
Iowa 4.3 11.6
Kansas 6.2 14.4
Kentucky 6.4 11.6
Louisiana 6.5 12.5
Maine 5.8
Maryland 4.2 13.4
Massachusetts 5.0 6.4
Michigan 5.6 15.6
Minnesota 4.1 7.4
Mississippi 7.1 13.7
Missouri 6.1 13.7
Montana 5.1
Nebraska 5.1 9.9
Nevada 5.7 9.0
New Hampshire
New Jersey 3.9 10.9
New Mexico 5.0
New York 4.5 9.7
North Carolina 5.5 15.9
North Dakota 4.6
Ohio 6.2 15.1
Oklahoma 6.4 16.3
Oregon 4.9
Pennsylvania 5.8 14.3
Rhode Island 5.0 15.3
South Carolina 5.2 10.9
South Dakota 6.0
Tennessee 6.1 15.1
Texas 5.3 11.1
Utah 5.3
Vermont 5.8
Virginia 5.6 13.5
Washington 4.7 9.1
West Virginia 7.3
Wisconsin 4.9 16.1
Wyoming 5.8
United States 5.3 12.64
WHITE BLACK
Health Disparities
Source: Kochanek et al. Deaths:
Final Data for 2009. National Vital
Statistics Reports, Vol 6 no 3.
Hyattsville, MD: National Center
for Health Statistics. 2011.
Blank indicates data is not avail-
able for this subgroup.
Comparison to
Other Nations
p
When health in the United States is compared
to health in other countries, the picture is disap-
pointing. In an often cited report from 2000, the
World Health Organization (WHO) ranked the U.S.
health care system 37th in the world.
12
Although
this report is often criticized as outdated, the WHO
in its World Health Statistics 2012 publication
compares the United States to other countries of
the world on a variety of health related measures.
13
While the U.S. does outperform many countries,
it is far from the best in many of the key measures
used to gauge healthiness, and it lags behind its
peers in other developed countries.
Life expectancy is a measure that indicates the
number of years that a newborn can expect to
live. Japan is the perennial leader in this measure,
with a life expectancy of over 86 years on aver-
age for females and just under 80 years for males
(San Marino men have a longer life expectancy at
82 years).
14
With a life expectancy of 81 years for
women and 76 years for men, the United States
ranks 29th among the 193 reporting nations of the
WHO.
15
Table 8 (page 26) lists a few other coun-
tries for comparison purposes. Life expectancy in
the U.S. doesnt compare to most other developed
countries as U.S. male life expectancy rates are on
par with Chile, Cuba, and Slovenia and U.S. female
life expectancy rates are on par with Colombia,
Cuba, Czech Republic, and Poland.
If you view life expectancy at a more granular
level, i.e. at the county level, and compare it to
other leading nations, U.S. life expectancy rates
appear even worse.
16
While many U.S. counties
(33 counties for men and 8 counties for women)
exceed the average life expectancy of the 10 lead-
ing nations, by far the majority of U.S. counties lag
behind these other nations. In fact, 92 U.S. coun-
ties for men and 2 U.S. counties for women have
life expectancy rates similar to those experienced
by other leading nations back in 1957 or earlier.
Life expectancy rates in 1,406 U.S. counties are
now further behind those of developing nations
than they were 7 years earlier.
17
One of the underlying causes for these differ-
ences is the gap in infant mortality rates between
the United States and many other countries (Table
8 on page 26). In 2011, the infant mortality rate for
the U.S. was 6 deaths per 1,000 live births, ranking
the U.S. 40th among WHO nations.
18
Rates for
Denmark, Portugal, Italy, Germany, France, Czech
Republic, Norway, and Ireland are all half of the
U.S. rate. These countries also have considerably
lower infant mortality rates than that of non-His-
panic whites in the United States, the ethnic/racial
group with the lowest rates in the United States.
It should be noted that this rate is dependent on
the classication of infant mortality, which varies
between countries.
Differences in healthy life expectancy are also
impacted by the effectiveness of treating disease,
especially diseases that are amenable to care
such as bacterial infections, treatable cancers,
diabetes, cardiovascular and cerebrovascular
disease, some ischemic heart disease, and com-
plications from common surgical procedures.
The age-adjusted amenable mortality rate before
age 75 for the United States was 95.5 deaths per
100,000 population in 2006 to 2007.
19
This is a
considerable improvement from 120.2 deaths per
100,000 population in 1997 to 1998, but the rate
of improvement was much slower than in other
Organization for Economic Cooperation and
Development (OECD) nations studied. The rate
in the U.S. remains 50 percent higher than the
rates in Australia, France, Japan, and Italy. This
study estimated that if the United States achieved
12. The World Health Report 2000 - Health Systems: Improving Performance. Bulletin- World Health Organization. 2000;78:1064.
13. World Health Organization (2012). World Health Statistics 2012.
15. Holstein AD. Health outcomes and the cost-quality trade-off in health care: Empirical study of OECD countries. The International
Business Economics Research Journal. 2004;3(7).
16. Kulkarni SC. Falling behind: Life expectancy in US counties from 2000 to 2007 in an international context. Population Health Metrics.
2011;9(1):16. doi: 10.1186/1478-7954-9-16.
17. Kulkarni SC. Falling behind: Life expectancy in US counties from 2000 to 2007 in an international context. Population Health Metrics.
2011;9(1):16. doi: 10.1186/1478-7954-9-16.
19.Nolte E. Variations in amenable mortalitytrends in 16 high-income nations. Health Policy. 2011;103(1):47.
International Comparisons
Table 8
International
Comparisons
*Total expenditure
on health as % of
gross domestic
product
**Rank among
193 member
countries of WHO
Australia 4 22 80 2 84 7 8.7
Austria 4 22 78 14 83 11 11.0
Belgium 4 22 77 27 83 11 10.7
Canada 5 33 79 7 83 11 11.3
China 13 74 72 53 76 76 5.1
Czech Republic 3 9 74 40 80 35 7.9
Denmark 3 9 77 27 81 32 11.4
Finland 2 1 77 27 83 11 9.0
France 3 9 78 14 85 2 11.9
Germany 3 9 78 14 83 11 11.6
Greece 4 22 78 14 83 11 10.3
Hungary 5 33 70 80 78 52 7.3
Ireland 3 9 77 27 82 26 9.2
Israel 4 22 80 2 83 11 7.6
Italy 3 9 79 7 84 7 9.5
Japan 2 1 80 2 86 1 9.5
Mexico 13 74 73 44 78 52 6.3
Netherlands 3 9 78 14 83 11 11.9
New Zealand 5 33 79 7 83 11 10.1
Norway 3 9 79 7 83 11 9.5
Poland 5 33 71 66 80 35 7.5
Portugal 3 9 76 34 82 26 11.0
San Marino 2 1 82 1 85 2 7.1
Spain 4 22 78 14 85 2 9.5
Sweden 2 1 79 7 83 11 9.6
Switzerland 4 22 80 2 84 7 11.5
United Kingdom 4 22 78 14 82 26 9.64
United States of America 6 40 76 34 81 32 17.89
HEALTH
EXPENDITURE (%)*
MALE RANK** FEMALE RANK**
LIFE EXPECTANCY (YEARS AT BIRTH)
DEATHS PER 1,000
LIVE BIRTHS
INFANT MORTALITY RATE
RANK**
International Comparisons
rates on par with comparative countries, between
59,500 and 84,300 deaths before age 75 would
have been saved.
Per capita health care spending in the United
States continues to lead the world. The median
expenditure among OECD countries is around
$3,000 per person; in the U.S., it is over $8,000 per
person.
20
The annual growth rate of spending in
the United States from 2000 through 2010 was 4.3
percent, slightly under the average of 4.7 percent
among OECD countries.
21
Utilization of health care
in the United States also exceeds other OECD
countries with 25 percent of adults taking at least
4 prescriptions regularly compared to a median of
17 percent among studied countries. U.S. patients
receive 91 MRI exams per 100,000 population
compared to under 50 exams per 100,000 popula-
tion in the other 5 reporting countries.
22
Not only does the U.S. spend the most on health
care, it also has one of the highest health inequali-
ties compared to other developed countries. The
U.S. ranks among the worst OECD countries for
child health well-being, having an inequality higher
than average.
23
Although the U.S. has the highest
national income per person, it continues to rank
as the worst country for income inequality. This
inequality is thought to explain why it has the high-
est index of health and social problems compared
to other wealthy nations.
24
Physical inactivity is a major contributor to
disease worldwide and is the fourth leading risk
factor for global mortality.
25
With roughly a third of
the worlds population inactive, physical inactivity
is responsible for an estimated 6 to 10 percent of
non-communicable diseases such as heart disease,
type 2 diabetes, breast cancer, and colon cancer.
Overall it is responsible for 9 percent of premature
deaths5.3 million deaths in 2008.
26
In the U.S.,
40 percent of the population is physically inactive,
which is higher than both Canada at 34 percent
and Mexico at 38 percent. It is estimated that
eliminating physical inactivity in the U.S. could add
nearly a year to life expectancy and dramatically
reduce the burden of chronic diseases.
27
Obesity is another major contributor to disease.
North America has 34 percent of the worlds bio-
mass due to obesity, yet it only makes up 6 percent
of the world population. Asia, on the other hand,
has 61 percent of the world population yet only 13
percent of its biomass due to obesity.
28
While the
U.S. is only one of several countries that make up
North America, they are the only North American
nation to rank in the heaviest 10.
Despite the highest per capita spending on
health care, the U.S. doesnt fare well in most
comparisons to other developed countries. Key
indicators of health and the health care system are
substantially lower in the U.S. compared to other
countries. The U.S. has some of the most state-of-
the-art health care facilities, yet behavioral factors
such as physical inactivity, smoking, and dietary
choices, combined with disparities, result in poor
performance. Innovative solutions from the indi-
vidual to the national level are needed in order to
address the health care challenges of the future.
20. Organization for Economic Co-operation and Development. OECD Health Data 2012.
21. Organization for Economic Co-operation and Development. OECD Health Data 2012.
22. Squires DA. The U.S. health system in perspective: A comparison of twelve industrialized nations. Issue Brief (Commonwealth Fund).
2011;16:1-14.
23. UNICEF. The children left behind: A league table of inequality in child well-being in the worlds rich countries. Innocenti Research
Centre: Report Card 9. 2010.
24. Wilkinson RG, Prickett KE. Income inequality and social dysfunction. Annual Review of Sociology. 2009.
25. World Health Organization. Global Health Risks Mortality and Burden of Disease Attributable to Selected Major Risks. Updated 2009.
26. Lee I, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT. Effect of physical inactivity on major non-communicable diseases world-
wide: An analysis of burden of disease and life expectancy. The Lancet. 2012.
27. Lee I, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT. Effect of physical inactivity on major non-communicable diseases world-
wide: An analysis of burden of disease and life expectancy. The Lancet. 2012.
28. Walpole SC, Prieto-Merino D, Edwards P, Cleland J, Stevens G, Roberts I. The weight of nations: An estimation of adult human
biomass. BMC Public Health. 2012.
Methodology
The methodology underlying Americas
Health Rankings
reects the evolving

expectations and role of health in our
society and our ability to measure
various aspects of health. For each
measure the raw data, as obtained
from the stated sources and adjusted
for age as appropriate, is presented
and referred to as value. For several
measures, such as Infant Mortality and
Infectious Disease, data from multiple
years are combined to provide sufcient
sample size to be meaningful.
All age-adjusted data utilizes the
population prole for the middle year
of data. For example, if the data is from
2007 to 2009, the standard population
is set at 2008.
The score for each state is based
on the following formula. The score is
stated as a decimal.
STATE VALUE NATIONAL MEAN
SCORE =
STANDARD DEVIATION OF ALL
STATE VALUES
Often referred to as a Z-score, this
score indicates the number of standard
deviations a state is above or below
the national mean. This results in a
score of 0.00 for a state with the same
value as the national mean. States that
have a higher value than the national
average will have a positive score while
those with a lower value will have a
negative score. Scores are calculated
to 3 decimal places and, to prevent an
extreme value from excessively inuenc-
ing a nal score, the maximum score
any state could receive for a measure is
plus or minus 2.
Where a value for the United States
overall is not available, the national
mean is set at the average value of the
states and the District of Columbia. For
data sourced from BRFSS, the median
of all states is substituted for the
national mean in the above calculation.
The overall score was calculated by
adding the scores of each measure mul-
tiplied by its percentage of total overall
ranking and the effect it has on health
(Table 9 on page 29). Note: Scores
reported for individual measures may
not add up to the overall scores due to
the rounding of numbers.
The ranking is the ordering of each
state according to value. Ties in scores
are assigned equal rankings.
Overall comparisons to prior years
are not presented this year. Signicant
changes in the methodology used by
the BRFSS do not allow for year-to-year
comparisons. See the section below
for more information on the BRFSS
changes.
The 2012 Edition uses the improved
methodology introduced in the
2009 Edition to calculate state ranks.
Rankings presented in this edition are
comparable to rankings published in
the 2011, 2010 and 2009 Editions, but
they are not comparable to the rankings
published in the earlier, printed
editions. However, all prior rankings,
including 1990 through 2008, have
been recalculated using the improved
method. They are available at www.
americashealthrankings.org and can
be compared to the rankings in this
print edition. All historical comparisons
discussed in this report are to rankings
calculated using the improved method.
Weighting of Measures
Three criteria were considered when
assigning weights to measures.
1. What effect does a measure have
on overall health?
2. Is the effect measured solely by this
measure or is it included in other
measures?
3. How reliable is the data supporting
a measure?
The nal weights, presented in Table
9 (page 29), are based on input from
experts in 1990 and 1991 and the
Scientic Advisory Committee and its
continuing methodological review (Page
11). The weights of the measures total
100 percent. Determinants account for
75 percent of the overall ranking and
outcomes account for 25 percent, a shift
from the 50/50 balance in the original
1990 index. This reects the importance
and growing availability of determinant
data. The column labeled % of Total
indicates the weight of each measure
in determining the overall ranking. For
example, prevalence of smoking is 7.5
percent of Americas Health Rankings
.
The column labeled Effect on Score
presents how each measure positively
or negatively relates to the overall
ranking. For example, a high prevalence
of smoking has a negative effect on
score and will lower the ranking of a
state. An increase in the percentage of
high school graduates has a positive
effect on score and will increase the
overall ranking of a state.
Impact of Model Changes
When model changes are implemented,
such as the addition of new metrics, it
becomes difcult to discern whether
a states change in overall rank is a
true change or whether it is caused
by the inclusion of new metrics. Prior
to deciding to change the model, the
proposed new metrics and weights are
placed into the previous years model
to see what impact adding or removing
metrics has on each states overall
ranking.
In order to make an accurate year-to-
year comparison on overall health, it is
necessary to use the same metrics and
weights for each year. Therefore, the
prior years overall score and rank is
recalculated using all changed metrics
and/or weights, and this adjusted
score and rank is used for comparisons
between this edition and the immedi-
ately prior edition.
Methodology
Table 9
Weight of Individual Measures, 2012 Edition
NAME OF MEASURE % OF TOTAL EFFECT ON SCORE
DETERMINANTS
OUTCOMES
BEHAV AA IORS
Smoking 7.5 Negative
Binge Drinking 5.0 Negative
Obesity 5.0 Negative
Sedentary Lifestyle 2.5 Negative
High School Graduation 5.0 Positive
COMMUNITY AND ENVIRONMENT
Violent Crime 5.0 Negative
Occupational Fatalities 2.5 Negative
Infectious Disease 5.0 Negative
Children in Poverty 5.0 Negative
Air Pollution 5.0 Negative
POLICY
Lack of Health Insurance 5.0 Negative
Public Health Funding 2.5 Positive
Immunization Coverage 5.0 Positive
CLINICAL CARE
Low Birthweight 5.0 Negative
Primary Care Physicians 5.0 Positive
Preventable Hospitalizations 5.0 Negative
Diabetes 2.0 Negative
Poor Mental Health Days 2.0 Negative
Poor Physical Health Days 2.0 Negative
Geographic Disparity 5.0 Negative
Infant Mortality 5.0 Negative
Cardiovascular Deaths 2.0 Negative
Cancer Deaths 2.0 Negative
Premature Death 5.0 Negative
OVERALL HEALTH RANKING 100.0
Revised BRFSS Methodology
The Behavioral Risk Factor Surveillance System (BRFSS)
is a state-based system of health surveys that collects
information on health risk behaviors, preventive health
practices, and health care access primarily related to
chronic disease and injury. BRFSS was established in 1984
by the Centers for Disease Control and Prevention (CDC).
Currently, data are collected monthly in all 50 states, the
District of Columbia, Puerto Rico, the U.S. Virgin Islands,
and Guam. More than 500,000 adults were interviewed
in 2011, making the BRFSS the largest telephone health
survey in the world.
1
BRFSS introduced 2 changes to their telephone survey
this year that affected data presented in this report. The
rst change is a revised method of analysis. Survey data
is always adjusted to reect who completes a survey in
comparison to the population being surveyed. Previously,
BRFSS had used a process called post-stratication that
allowed them to correct for about half a dozen differ-
ences among the completed surveys and the population.
Starting with this edition, a process called raking has
been adopted which allows them to now adjust for over a
dozen differences. This becomes increasingly important as
you get more diverse segments within the population and
improves the accuracy of the survey estimates.
2
The second change is to survey households that use a
cell phone as their primary residential phone and do not
have a landline. This portion of the population is increas-
ing rapidly, and the prior, landline only surveys were not
reaching these households. The CDC conducted a study
and found 4 demographic groups in which the majority
live in households without landlines: adults aged 25 to
34, adults living with only unrelated roommates, adults
renting their home, and adults living in poverty.
3
The
survey still does not capture responses from those without
a phone, and the CDC, similar to all phone surveys, faces
increasing difculty reaching those who screen all calls.
uses 7 metrics that rely

on BRFSS data: prevalences of smoking, obesity, binge
drinking, sedentary lifestyle, and diabetes, and the
number of poor physical health days and poor mental
health days in the last 30 days. The changes in the BRFSS
methodology do not allow comparisons to be made
between the values of these metrics in the current edition
and the values presented in prior editions.
1. BRFSS- CDCs Behavioral Risk Factor Surveillance System http://www.cdc.
gov/brfss/index.htm. Accessed November 9, 2012.
2. Methodologic changes in the behavioral risk factor surveillance system in
2011 and potential effects on prevalence estimates http://www.cdc.gov/
mmwr/preview/mmwrhtml/mm6122a3.htm?s_cid=mm6122a3_w. Accessed
November 9, 2012.
3. Blumberg PD,Stephen J, Luke JV. Wireless substitution: Early release of
estimates from the national health interview survey, JanuaryJune 2011.
http://www.cdc.gov/nchs/data/nhis/earlyrelease/wireless201112.pdf.
Published 12/21/2011. Accessed November 9, 2012.
Measures
Selection of Measures
Four primary considerations drove the
design of Americas Health Rankings
and the selection of the individual

measures:
1. The overall rankings had to represent
a broad range of issues that affect a
populations health.
2. Individual measures needed to
use common health measurement
criteria.
3. Data had to be available at a state
level.
4. Data had to be current and updated
periodically.
While not perfect, the measures
selected are believed to be the best
available indicators of the various
aspects of healthiness at this time and
are consistent with past reports.
For Americas Health Rankings
to
continue to meet its objectives, it must
evolve and incorporate new information
as it becomes available. The Scientic
Advisory Committee provides guidance
for the evolution of the rankings,
balancing the need to change with
the desire for longitudinal comparabil-
ity. Over the last few years, change is
being driven by: 1) acknowledgement
that health is more than years lived
but also includes the quality of those
years; 2) data about the quality and cost
of health care delivery are becoming
available on a comparative basis; and 3)
measurement of the additional deter-
minants of health are being initiated
and/or improved. The committee also
emphasizes that the real impact on
health will be made by addressing the
determinants, and making improve-
ments on these items will affect the
long-term health of the population. The
determinants are the predictors of our
future health.
As with all indices, the positive and
negative aspects of each measure
must be weighed when choosing and
developing them. These aspects for
consideration include: 1) the inter-
dependence of the different measures;
2) the possibility that the overall ranking
may disguise the effects of individual
measures; 3) an inability to adjust
all data by age and race; 4) an over-
reliance on mortality data; and 5) the
use of indirect measures to estimate
some effects on health. These concerns
cannot be addressed directly by
adjusting the methodology; however,
assigning weights to the individual
measures can mitigate their impact
(Table 9 on page 29).
Determinants and Outcomes
The 24 measures that comprise
are of 2
types determinants and outcomes.
Determinants represent those actions
that can affect the future health of the
population, whereas outcomes repre-
sent what has already occurred, either
through death, disease, or missed days
due to illness.
For further clarity, determinants are
divided into four groups: Behaviors,
Community and Environment, Policy,
and Clinical Care. These 4 groups
of measures inuence the health
outcomes of the population in a state,
and improving these inputs will improve
outcomes over time. Most measures are
actually a combination of activities in
all 4 groups. For example, the preva-
lence of smoking is a behavior that is
strongly inuenced by the community
and environment in which we live, by
public policy including taxation and
restrictions on smoking in public places,
and by the care received to treat the
chemical and behavioral addictions
associated with tobacco. However, for
simplicity, we placed each measure in a
single category.
For a state to improve the health of
its population, efforts must focus on
changing the determinants of health.
If a state is signicantly better in its
score for determinants than its score
for outcomes, it will likely improve its
overall health ranking in the future.
Conversely, if a state is worse in its
score for determinants than its score for
outcomes, its overall health ranking will
more likely decline over time.
Table 10 (page 31) presents the
overall scores for the determinants,
outcomes, and implications for the
future. Table 11 (page 31) displays
the top 10 and bottom 10 states for
determinants, while Table 12 (page
31) depicts the top 10 and bottom 10
states for outcomes.
When compared to other states,
Vermont, Connecticut, New Hampshire,
Maine, and Hawaii have a much
higher score for determinants than for
outcomes, providing a strong indica-
tion they will improve over time. Texas,
Louisiana, Mississippi, South Carolina,
and Arkansas show a strong indica-
tion that they will decline over time
compared to other states.
Measures
Alabama -0.259 -0.262 Neutral
Alaska 0.128 -0.045 Neutral
Arizona 0.056 0.083 Neutral
Arkansas -0.482 -0.235 Negative
California 0.12 0.143 Neutral
Colorado 0.386 0.163 Positive
Connecticut 0.608 0.212 Positive
Delaware -0.078 0.015 Neutral
Florida -0.015 -0.123 Neutral
Georgia -0.182 -0.08 Neutral
Hawaii 0.682 0.295 Positive
Idaho 0.294 0.131 Neutral
Illinois -0.083 0.024 Neutral
Indiana -0.284 -0.057 Negative
Iowa 0.059 0.241 Neutral
Kansas 0.094 0.058 Neutral
Kentucky -0.255 -0.215 Neutral
Louisiana -0.661 -0.277 Negative
Maine 0.506 0.116 Positive
Maryland 0.331 0.005 Positive
Massachusetts 0.62 0.259 Positive
Michigan -0.226 -0.043 Neutral
Minnesota 0.514 0.307 Positive
Mississippi -0.63 -0.308 Negative
Missouri -0.317 -0.086 Negative
Montana 0.005 0.032 Neutral
Nebraska 0.31 0.204 Neutral
Nevada -0.247 -0.033 Negative
New Hampshire 0.646 0.251 Positive
New Jersey 0.449 0.195 Positive
New Mexico -0.117 0.048 Neutral
New York 0.253 0.145 Neutral
North Carolina -0.036 -0.07 Neutral
North Dakota 0.427 0.116 Positive
Ohio -0.177 -0.068 Neutral
Oklahoma -0.264 -0.2 Neutral
Oregon 0.392 0.134 Positive
Pennsylvania 0.1 0.005 Neutral
Rhode Island 0.467 0.12 Positive
South Carolina -0.402 -0.132 Negative
South Dakota 0.136 -0.046 Neutral
Tennessee -0.146 -0.171 Neutral
Texas -0.364 0.036 Negative
Utah 0.59 0.215 Positive
Vermont 0.947 0.249 Positive
Virginia 0.251 0.017 Positive
Washington 0.37 0.157 Positive
West Virginia -0.385 -0.271 Neutral
Wisconsin 0.326 0.16 Neutral
Wyoming 0.155 0.081 Neutral
Table 11
2012 Determinants Highest and
Lowest Ranked States
RANK STATE RANK STATE
1 Vermont 50 Louisiana
2 Hawaii 49 Mississippi
3 New Hampshire 48 Arkansas
4 Massachusetts 47 South Carolina
5 Connecticut 46 West Virginia
6 Utah 45 Texas
7 Minnesota 44 Missouri
8 Maine 43 Indiana
9 Rhode Island 42 Oklahoma
10 New Jersey 41 Alabama
Table 10
Determinants and Outcomes, 2012 Edition
SCORE FOR ALL SCORE FOR ALL INFLUENCE ON
DETERMINANTS* OUTCOMES* FUTURE
Table 12
2012 Outcomes Highest and
Lowest Ranked States
RANK STATE RANK STATE
1 Minnesota 50 Mississippi
2 Hawaii 49 Louisiana
3 Massachusetts 48 West Virginia
4 New Hampshire 47 Alabama
5 Vermont 46 Arkansas
6 Iowa 45 Kentucky
7 Utah 44 Oklahoma
8 Connecticut 43 Tennessee
9 Nebraska 42 South Carolina
10 New Jersey 41 Florida
*Scores indicate the
weighted number of
standard deviations a
state is above or below
the national norm.
Measures
Description of Measures
Table 13 summarizes each of the core measures, including data source and data year,
in this Edition of Americas Health Rankings
.
A short discussion of each measure immediately follows. The data for each year is
the most current data available at the time the report was compiled.
The full data tables are available at www.americashealthrankings.org/defn.
Table 13
Summary Description of Measures, 2012 Edition
DETERMINANTS DESCRIPTION SOURCE DATA YEAR(S)
BEHAVIORS
COMMUNITY & ENVIRONMENT
Smoking
Binge Drinking
Obesity
Sedentary Lifestyle
High School Graduation
Violent Crime
Occupational Fatalities
Infectious Disease
Children in Poverty
Air Pollution
Percentage of population over age 18 that smokes on a
regular basis (smoked at least 100 cigarettes in their lifetime
and currently smoke every day or some days).
Percentage of population over age 18 that drank excessively
in the last 30 days (ve or more drinks for males and four or
more drinks for females on one occasion).
Percentage of population over age 18 estimated to be obese,
with a body mass index (BMI) of 30.0 or higher.
Percentage of population over age 18 who report doing no
physical activity or exercise (such as running, calisthenics,
golf, gardening, or walking) other than their regular job in the
last 30 days.
Percentage of incoming ninth graders who graduate in four
years from a high school with a regular degree.
Number of murders, rapes, robberies, and aggravated
assaults per 100,000 population.
Number of fatalities from occupational injuries per 100,000
workers.
Number of reported cases of measles, pertussis, syphilis and
Hepatitis A per 100,000 population.
Percentage of persons under age 18 who live in households
at or below the poverty threshold.
Average exposure of the general public to particulate matter
of 2.5 microns or less in size (PM2.5).
CDC BRFSS
CDC BRFSS
CDC BRFSS
CDC BRFSS
NCES
FBI
CFOI BLS
CDC MMWR
Census Bureau CPS
EPA, Census Bureau
2011
2011
2011
2011
20082009
school year
2010
2009-prelim 2011
20092010
2011
20092011
CORE MEASURES
CLINICAL CARE
DETERMINANTS DESCRIPTION SOURCE DATA YEAR(S)
POLICY
Lack of Health Insurance
Public Health Funding
Immunization Coverage
Low Birthweight
Primary Care Physicians
Preventable Hospitalizations
Diabetes
Poor Mental Health Days
Poor Physical Health Days
Geographic Disparity
Infant Mortality
Cardiovascular Deaths
Cancer Deaths
Premature Death
Percentage of the population that does not have health
insurance privately, through their employer, or the
government.
State funding dedicated to public health as well as
federal funding directed to states by the Centers
for Disease Control and Prevention and the Health
Resources and Services Administration.
Average percentage of children ages 19 to 35 months
who have received these individual vaccinations: four
or more doses of DTP, three or more doses of poliovirus
vaccine, one or more doses of any measles-containing
vaccine, and three or more doses of HepB vaccine.
Percentage of babies weighing less than 2,500 grams
(5 pounds, 8 ounces) at birth.
Number of primary care physicians (including general
practice, family practice, OB-GYN, pediatrics, and
internal medicine) per 100,000 population.
Discharge rate among the Medicare population for
diagnoses that are amenable to non-hospital based care.
Percentage of population over age 18 who have been
told by a health professional that they have diabetes
(does not include pre-diabetes or diabetes during
pregnancy).
Number of days in the previous 30 days when a person
indicates their activities were limited due to mental
health difculties.
Number of days in the previous 30 days when a person
indicates their activities were limited due to physical
health difculties.
Variation in overall mortality rates among the counties
within a state.
Number of infant deaths (before age 1) per 1,000 live
births.
Number of deaths due to all cardiovascular diseases,
including heart disease and strokes, per 100,000
population.
Number of deaths due to all causes of cancer per
100,000 population.
Number of years of potential life lost prior to age 75 per
100,000 population.
Census Bureau CPS
TFAH
CDC NIP
CDC NCHS
AMA
Dartmouth Atlas
CDC BRFSS
CDC BRFSS
CDC BRFSS
CDC NCHS
CDC NCHS
CDC NCHS
CDC NCHS
CDC NCH
20102011
20102011
2011
2010
2010
2010
2011
2011
2011
20072009
20082009
20072009
20072009
2009
OUTCOMES
Health Determinants
BEHAVIORS
Five measures reect behaviors that are
potentially modiable through a com-
bination of personal, community, and
clinical interventions: smoking, obesity,
binge drinking, sedentary lifestyle, and
high school graduation. These items are
determinants that measure behaviors
and activities having an immediate or
delayed effect on health and are promi-
nently included in these rankings.
However, the selection of these 5
measures does not imply that they are
the only underlying behaviors that need
to be addressed in a comprehensive
public health effort. For example, the
American Academy of Family Physicians
suggests that to improve health, indi-
viduals should:
Avoid ony lorm ol ro6occo.
Eor o |eolr|y dier.
Exercise regulorly.
Drin| olco|ol in moderorion, il or oll.
Avoid use ol illegol drugs.
Frocrice sole sex.
Use seor 6elrs (ond cor seors lor
children) when riding in a car or
truck.
Avoid sun6or|ing ond ronning
booths.
Keep immunizorions up-ro-dore.
See o docror regulorly lor prevenrive
care.
29
Measures
Additional suggestions for individual
initiatives are in Healthy People 2020,
pu6lis|ed 6y r|e U.S. Deporrmenr
ol Heolr| ond Humon Services,
Wos|ingron, D.C., ovoilo6le or
www.healthypeople.gov.
The impact of changing behaviors is
|uge. CDC esrimores r|or il ro6occo
use, poor diet, and physical inactivity
were eliminated, 80 percent of heart
disease and stroke, 80 percent of Type
2 diabetes, and 40 percent of cancer
would be prevented.
30
Smoking measures the percentage
of the population over age 18 who
smoke tobacco products regularly. It
is dened as the percentage of adults
who self-report smoking at least 100
cigarettes in their lifetime and who
currently smoke every day or some
days. The 2012 ranks, based on data
lrom CDC's 2011 Be|oviorol Ris| Focror
Surveillonce Sysrem (BRFSS), ore or
www.americashealthrankings.org/all/
smo|ing. T|e BRFSS relep|one survey
has traditionally been completed by
people using londlines. During r|e
lelding ol r|e 2011 BRFSS, r|e mer|-
odology was updated to include cellular
telephones due to the large number of
households that contain only cellular
telephones and no landline telephones.
Becouse ol r|ese c|onges, esrimores
of smoking prevalence from the 2012
Edirion onword connor 6e compored
ro esrimores lrom previous yeors. S|ilrs
in estimates from previous years may
be the result of the new methods,
rather than measurable changes in the
percentages.
Smo|ing |os o very well documenred
adverse impact on overall health. It is
the leading cause of preventable death
in r|e U.S. To6occo use is esrimored ro
be responsible for about 1 in 5 deaths
or about 443,000 deaths per year.
31
Smo|ing domoges neorly every orgon
in the body and causes many diseases,
including respiratory disease, heart
disease, stroke, cancer, preterm birth,
low birthweight, and premature death.
32
Berween r|e yeors 2001 ond 2004,
estimated annual smoking attributable
health care costs exceeded $95 billion.
31
Not only are smokers themselves at
increased risk for negative health conse-
quences, so are those who are exposed
to secondhand smoke, as it has serious
effects on the population causing respi-
ratory infections in children and heart
disease and lung cancer in adults.
33
Smo|ing is o lilesryle 6e|ovior r|or
an individual can directly inuence
with support from the community
and, as required, clinical intervention.
Cessorion, even in o longrime smo|er,
can have profound benets on current
health status as well as long term
outcomes.
34
Smo|ers w|o quir 6elore
35 years of age reduce their risk of
premature death to almost the same
level as non-smokers.
35
A wide variety of
intervention types have been found to
be effective in leading to smoking ces-
sation at the individual and community
levels.
36
Many policy efforts have been
tried over the past several decades
including excise taxes and smoking
6ons. Bor| ol r|ese policy opprooc|es
have been shown to be tremendously
effective in leading to cessation,
preventing non-smokers from starting,
and decreasing smoking related health
problems.
37, 38
Due ro r|e widespreod
negative health effects of secondhand
smoke, reducing the prevalence of
smoking and creating smoke-free envi-
ronments can have a profound impact
on the entire community.
39
For more
information and resources to help you
familydoctor.org/familydoctor/en/prevention-wellness/staying-healthy/healthy-living/preventive-services-
for-healthy-living.html. Updated 2010. Accessed August 14, 2012.
30. Mensah, GA. Global and Domestic Health Priorities: Spotlight on Chronic Disease, National Business
Group on Health Webinar, May 23, 2006.
31. Adhikari B. Smoking-attributable mortality, years of potential life lost, and productivity lossesUnited
States, 20002004. Morb Mortal Weekly Rep. 2008;57(45):1226.
32. Centers for Disease Control and Prevention (CDC). Smoking and Tobacco Use. June 2, 2012. http://www.
cdc.gov/tobacco/. Accessed August 3, 2012.
33. US Department of Health and Human Services. The Health Consequences of Involuntary Exposure to To-
bacco Smoke: A Report of the Surgeon General. Atlanta, GA: Centers for Disease Control and Prevention,
Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health
Promotion, Ofce on Smoking and Health; 2006.
34. US Department of Health and Human Services. The Health Consequences of Smoking: A Report of the
Surgeon General. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Chronic
Disease Prevention and Health Promotion, Ofce on Smoking and Health; 2004.
35. Taylor Jr. DH, Hasselblad V, Henley SJ, Thun MJ, Sloan FA. Benets of smoking cessation for longevity. Am
J Public Health. 2002;92(6):990-996. http://articles.sirc.ca/search.cfm?id=S-833157; .
36. Lemmens V, Oenema A, Knut IK, Brug J. Effectiveness of smoking cessation interventions among adults: A
systematic review of reviews. European Journal of Cancer Prevention. 2008;17(6):535.
37. Chaloupka FJ. Effectiveness of tax and price policies in tobacco control. Tob Control. 2011;20(3):235.
38. Naiman A. Association of anti-smoking legislation with rates of hospital admission for cardiovascular and
respiratory conditions. Canadian Medical Association. Journal CMAJ. 2010;182(8):761.
39. US Department of Health and Human Services. The Health Consequences of Involuntary Exposure to To-
bacco Smoke: A Report of the Surgeon General. Atlanta, GA: Centers for Disease Control and Prevention,
Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health
Promotion, Ofce on Smoking and Health; 2006.
quit, see www.smokefree.gov/.
The national median of regular
smokers is 21.2 percent of adults. The
percentage of the adult population
who smokes varies from a low of 11.8
percent in Utah to 29.0 percent in
Kentucky.
Binge Drinking measures the percent-
age of the population over age 18 who
drank excessively in the last 30 days. It
is dened as males having ve or more
drinks and females having four or more
drinks on one occasion. The 2012 ranks,
based on 2011 BRFSS self-report data,
are at www.americashealthrankings.
org/all/binge. The BRFSS telephone
survey has traditionally been completed
by people using landlines. During
the elding of the 2011 BRFSS, the
methodology was updated to include
cellular telephones due to the large
number of households that contain only
cellular telephones and no landline
telephones. Because of these changes,
estimates of binge drinking preva-
lence from the 2012 Edition onward
cannot be compared to estimates from
previous years. Shifts in estimates from
previous years may be the result of the
new methods, rather than measurable
changes in the percentages.
Binge drinking leads to acute impair-
ment and has adverse effects on health
due to the impact of alcohol-related
motor vehicle injuries and deaths,
increased aggression, and unintentional
injuries. Excessive alcohol consumption
can lead to fetal damage, liver diseases,
and cardiovascular diseases along with
other health risks.
40
Binge drinking con-
tributes signicantly to overall alcohol
consumption in adults, accounting for
half of all the annual alcohol consumed
nationally.
41
Excessive alcohol con-
sumption is the third leading cause of
preventable death in the U.S. with an
estimated 85,000 attributable deaths in
2000, half of which are directly related
to binge drinking.
42
Binge drinking was
also estimated to be responsible for $14
billion of the $24 billion spent on health
care due to excessive drinking in 2006.
43
Excessive drinking contributes signi-
cantly towards the nearly 35,000 annual
motor vehicle accident fatalities with a
third of all fatalities involving alcohol.
44
Binge drinking rates are highest among
18 to 25 year olds, but the majority of
binge drinkers are over 26 years old.
45
A wide variety of strategies have been
shown to be effective in reducing binge
drinking within a community, and the
U.S. Preventive Services Task Force
has published recommendations for
interventions to help curb problem
drinking.
46
The prevalence of binge drinking
varies from less than 11.0 percent in
Tennessee and West Virginia to 23.0
percent or more in Illinois, Iowa, North
Dakota, and Wisconsin. The national
median is 18.3 percent of adults who
binge drink.
Obesity is the percentage of the
adult population estimated to be
obese, dened as having a body
mass index (BMI) of 30.0 or higher.
BMI, as dened by CDC, is equal to
weight in pounds divided by height
in inches squared and then multiplied
by 703. CDC has a calculator for BMI
at www.cdc.gov/nccdphp/dnpa/bmi/
calc-bmi.htm. The 2012 ranks, based
on self-reported weight and height
from CDCs 2011 BRFSS data, are at
obesity. The BRFSS telephone survey
people using landlines. During the
elding of the 2011 BRFSS, the meth-
Because of these changes, estimates
of obesity prevalence from the 2012
Edition onward cannot be compared
to estimates from previous years. Shifts
percentages.
Obesity is one of the greatest
health threats to the U.S. It contributes
signicantly to a variety of serious
diseases, including heart disease,
diabetes, stroke, and certain cancers as
well as poor general health.
47
Obesity
is a leading cause of preventable
death in the U.S., causing an estimated
200,000 deaths annually.
48
The direct
medical costs for treating obesity
and obesity-related health problems
are overwhelming. In 2008 it was
estimated that $147 billion was spent
on obesity or obesity-related health
issues.
49
Obesity is more prevalent
than smoking and is highly associated
with chronic conditions and overall
poor physical health similar to smoking
and excessive alcohol consumption.
50
The causes of obesity are complex
and include lifestyle, the social and
physical environment, as well as genes
and medical history. Poor diet and
decreased physical activity are major
lifestyle contributors to obesity. Since
the 1980s, energy intake has steadily
climbed and energy expenditure
has declined, leading to a growing
energy imbalance which closely
mirrors the obesity rates.
51
There is
growing evidence illustrating the
40. Centers for Disease Control and Prevention (CDC). Alcohol and Public Health. July 26, 2012. http://www.
cdc.gov/alcohol/. Accessed August 3, 2012.
41. Centers for Disease Control and Prevention (CDC). Vital signs: Binge drinking prevalence, frequency, and
intensity among adults - United States, 2010. Morbidity and Mortality Weekly Report. 2012;61(1):14.
42. Mokdad, AH. Actual causes of death in the United States, 2000. JAMA 291.10 (2004):1238.
43. Bouchery EE. Economic costs of excessive alcohol consumption in the US, 2006. Am J Prev Med.
2011;41(5):516.
44. Bergen G. Vital signs: Alcohol-impaired driving among adults--United States, 2010. Morbidity and Mortality
Weekly Report. 2011;60(39).
45. Naimi TS. Binge drinking among US adults. JAMA. 2003;289(1):70.
46. US Preventive Services Task Force, Screening for Problem Drinking. Guide to Clinical Preventive Services.
Washington, DC: US Dept of Health and Human Services; 1996:567-582.
47. Centers for Disease Control and Prevention (CDC). Overweight and Obesity. May 24, 2012. http://www.
cdc.gov/obesity/. Accessed July 24, 2012.
48. Danaei G. The preventable causes of death in the United States: Comparative risk assessment of dietary,
lifestyle, and metabolic risk factors. PLoS Medicine. 2009;6(4).
49. Finkelstein EA, Trogdon JG, Cohen JW, Dietz W. Annual medical spending attributable to obesity: Payer-
and service-specic estimates. Health Affairs. 2009;28(5): w822-w831.
50. Sturm R. Does obesity contribute as much to morbidity as poverty or smoking? Public Health.
2001;115(3):229.
51. Finkelstein EA. Economic causes and consequences of obesity. Annu Rev Public Health. 2005;26(1):239.
importance of the environment in
the obesity epidemic and the need
for changes in the environment in
order to better facilitate changes in
lifestyle.
52
There have been successful
interventions targeting a wide variety
of populations with various strategies,
from school based prevention programs
to treatment interventions in aging
adults.
53, 54
While obesity is associated
with an increased risk of developing
numerous health conditions, weight loss
is associated with an attenuation
of those risks.
55
The CDC has put
together a list of useful resources for
community level interventions aimed
at lowering obesity rates, available
at www.cdc.gov/obesity/strategies/
communityStrategies.html.
The prevalence of obesity ranges
from 20.7 percent of the population
in Colorado to over one-third of the
population in Louisiana and Mississippi.
The national median of obese adults
is 27.8 percent. This means that more
than one in four adults are obese in the
United States that is more than 66
million adults with a body mass index of
30.0 or higher.
is the percentage
of adults who report doing no physical
activity or exercise (such as running,
calisthenics, golf, gardening, or walking)
other than their regular job in the last
30 days.
The 2012 ranks, based on self-reports
from CDCs 2011 BRFSS data, are at
www.americashealthrankings.org/
all/sedentary. This is the rst edition
to include sedentary lifestyle in the
Rankings.
Regular physical activity is one of the
most important elements of a healthy
lifestyle. A sedentary lifestyle increases
the risk of developing cardiovascular
disease, diabetes, hypertension, obesity,
and premature death.
56,57
Sedentary
lifestyle is responsible for an estimated
$24 billion in direct medical spending.
58
Increasing physical activity, especially
from a complete absence, cannot only
prevent numerous chronic diseases;
it can also help to manage them.
59
It
is estimated that physical inactivity is
responsible for almost 200,000 or 1 in
10 deaths each year.
60
Physical inactiv-
ity is associated with many social and
environmental factors as well including
low educational attainment, socio-
economic status, violent crime, and
poverty to name a few.
61
Even moderate
increases in physical activity can greatly
reduce risk for adverse health outcomes.
For resources and tips on how to add
physical activity to your life, see www.
cdc.gov/physicalactivity/everyone/
getactive/.
The percentage of sedentary
adults ranges from over 35 percent
of the adult population in Mississippi,
Tennessee and West Virginia to less
than 20 percent in California, Colorado,
Oregon, and Utah. The national median
is 26.2 percent.
High School Graduation estimates the
percentage of incoming ninth graders
who graduate within four years and
are considered regular graduates. The
National Center for Education Statistics
collects enrollment and completion
data and estimates the graduation rate
for each state. The rate is the number
of graduates divided by the estimated
count of freshmen four years earlier.
This estimated count of freshmen is the
sum of the number of 8th graders ve
years earlier, the number of 9th graders
four years earlier, and the number of
10th graders three years earlier divided
by three. Enrollment counts also include
a proportional distribution of students
not enrolled in a specic grade. The
2012 ranks, based on 2008 to 2009
school year data, are at www.ameri-
cashealthrankings.org/all/graduation.
Education is a vital contributor to
health as people must be able to learn
about, create, and maintain a healthy
lifestyle. Education can also help facili-
tate more effective health care visits as
patients must be able to understand
and participate in their care for optimal
results.
62
The connection between
education and health has been well
documented and spans almost all health
conditions.
63
Educational attainment is
Table 14
Top Improvements in High School Graduation (Increase in
percentage of ninth graders who graduate within 4 years)
LAST YEAR SINCE 2007 EDITION
STATE CHANGE STATE CHANGE
Utah +5.1% New York +12.6%
Louisiana, South Carolina (tie) +3.8% Tennessee +11.3%
North Dakota +3.6% Georgia +6.6%
Alaska +3.5% Arizona +5.7%
Kentucky +3.2% New Hampshire +5.6%
Measures
52. Papas MA. The built environment and obesity. Epidemiol Rev. 2007;29(1):129.
53. Shaya FT. School-based obesity interventions: A literature review. J Sch Health. 2008;78(4):189.
54. McTigue KM. Obesity in older adults: A systematic review of the evidence for diagnosis and treatment.
Obesity. 2006;14(9):1485.
55. Malnick SDH. The medical complications of obesity. QJM. 2006;99(9):565.
56. Hu FB. Sedentary lifestyle and risk of obesity and type 2 diabetes. Lipids. 2003;38(2):103.
57. King AC. Environmental and policy approaches to cardiovascular disease prevention through physical
activity: Issues and opportunities. Health Education Behavior. 1995;22(4):499.
58. Colditz GA. Economic costs of obesity and inactivity. Med Sci Sports Exerc. 1999;31(11 Suppl):S663-7.
59. Weiler R, Stamatakis E, Blair S. Should health policy focus on physical activity rather than obesity? Yes.
BMJ. 2010;340(7757):1170-1171.
60. Danaei G. The preventable causes of death in the United States: Comparative risk assessment of dietary,
lifestyle, and metabolic risk factors. PLoS Medicine. 2009;6(4).
61. King AC. Personal and environmental factors associated with physical inactivity among different racial
ethnic groups of US middle-aged and older-aged women. Health Psychology. 2000;19(4):354.
62. Peerson A. Health literacy revisited: What do we mean and why does it matter? Health Promot Interna-
tion. 2009;24(3):285.
63. Ross CE. The links between education and health. Am Sociol Rev. 1995:719.
also a strong predictor of overall adult
health and life expectancy.
64
Education
is strongly tied to higher earnings,
which is associated with lower rates of
uninsurance, allowing for greater access
to quality health care. The breadth
of health determining factors which
education affects is so large that invest-
ments in education have the potential
to improve health and save more lives
than medical advances.
65
Each addi-
tional year of education is associated
with an increase in many health pro-
moting behaviors, and policies aimed
at increasing education levels could
have tremendous impacts on health.
66
Increasing educational attainment in a
population has been shown to improve
the health status of the population.
67
The high school graduation rate
varies from over 89.0 percent of
incoming ninth graders who graduate
within four years in Wisconsin and
Vermont to less than 57.0 percent in
Nevada. The national average is 75.5
percent, compared to 74.7 percent in
the 2011 Edition.
Data are not adjusted for the
presence or quality of basic health
and consumer health education in the
curriculum, for continuing education
programs, or for other non-traditional
learning programs. Also, individual
states are increasingly altering gradu-
ation requirements, which may affect
their reported number of regular gradu-
ates, their graduation rate, and the
comparability of these rates across time.
COMMUNITY AND ENVIRONMENT
Five measures are used to represent
the community and the environment:
the violent crime rate, the occupa-
tional fatalities rate, the percentage of
children in poverty, the incidence of
infectious disease and exposure to air
pollution. Measures of community and
environment reect the reality that the
daily conditions in which we live our
lives have a great effect on achieving
optimal individual health. The presence
of pollution, violence, illegal drugs,
infectious disease, and unsafe work-
places are detrimental. In addition,
studies indicate that general socioeco-
nomic conditions and educational level
have a signicant relationship to the
healthiness of a communitys residents.
These determinants measure both
positive and negative aspects of the
community and environment of each
state and their effects on the popula-
tions health. Again, there are many
additional community efforts that
improve the overall health of a popula-
tion but are not directly reected in
these ve measures. Each community
has its own strengths, challenges, and
resources and should undertake a
careful planning process to determine
which action plans are best for them.
Violent Crime measures the annual
number of murders, rapes, robberies,
and aggravated assaults per 100,000
population. The 2012 ranks, based on
2010 data (Crime in the United States:
2010. Washington, D.C., Federal Bureau
of Investigation), are at www.ameri-
cashealthrankings.org/all/crime. The
data appearing in this years Edition
is the same as appeared in the 2011
Edition. The 2011 United States crime
statistics data was not released in time
to make it into this years report.
The violent crime rate measures
the effect that criminal behavior has
on the populations health, as violent
crimes often lead to injuries, disability,
or death. Violent crime also serves as
an indicator of the overall well-being
of a population since violent crime
can lead to psychological stress as
well as interfere with healthy lifestyles
by discouraging physical activity.
68, 69
Violent crime has wide ranging effects
on communities which only deteriorate
the health of the community. In 2010,
there were 1.2 million acts of violent
crime and over 16,000 homicides
committed in the U.S.
70
In 2010 for the
rst time since 1965 homicide was not
among the 15 leading causes of death
for all ages. However, it was still the 2nd
leading cause of death among 10 to 24
year olds, and 650,000 young people
were treated for injuries resulting from
violence.
71
Violent crime carries a signi-
cant economic burden as well, with an
estimated $65 billion in lost productivity
and $6 billion in direct medical costs.
72
For decades violence prevention has
been a priority among health ofcials.
Numerous intervention strategies have
been evaluated and many have been
shown to be effective.
73
The violent
crime rate is dependent upon many
factors, some of which may be unique
to certain communities. Therefore,
addressing violent crime may require
a thorough investigation of the root
causes.
The violent crime rate varies from
less than 200 offenses per 100,000
population in Maine, Vermont, New
Hampshire, and Wyoming to more
than 600 offenses per 100,000 popula-
tion in Nevada, Alaska, Delaware, and
Tennessee. The national average is 404
offenses per 100,000 population, down
205 offenses per 100,000 population
from the 1990 Edition.
Occupational Fatalities measures
the combined rate of fatal injuries in
the following industries: construction,
manufacturing, trade, transportation,
utilities, professional, and business
services, as dened by the North
American Industry Classication System
64. Molla MT, Madans JH, Wagener DK. Differentials in Adult Mortality and Activity Limitation by Years of Edu-
cation in the United States at the End of the 1990s. Population and Development Review. 2004;30(4):625-46.
65. Woolf SH. Giving everyone the health of the educated: An examination of whether social change would
save more lives than medical advances. Am J Public Health. 2007;97(4):679.
66. Cutler DM, Lleras-Muney A, National Bureau of Economic Research. Education and health: Evaluating
theories and evidence. Cambridge, MA.: National Bureau of Economic Research; 2006.
67. Lleras-Muney A. The relationship between education and adult mortality in the United States. The Review
of Economic Studies. 2005;72(1):189.
68. Curry A. Pathways to depression: The impact of neighborhood violent crime on inner-city residents in Balti-
more, Maryland, USA. Social Science Medicine. 2008;67(1):23.
69. Gomez JE. Violent crime and outdoor physical activity among inner-city youth. Prev Med. 2004;39(5):876.
70. Murphy SL. Deaths: Preliminary data for 2010. National Vital Statistics Reports. 2012;60(4).
71. Ibid.
72. Corso PS. Medical costs and productivity losses due to interpersonal and self-directed violence in the
United States. Am J Prev Med. 2007;32(6):474.
73. Sherman LW, National Institute of Justice (US). Preventing Crime What Works, What Doesnt, Whats Promis-
ing: A Report to the United States Congress. Dept. of Justice, Ofce of Justice Programs; 1998.
(NAICS). Rather than using an occu-
pational fatality rate for all workers,
this industry-adjusted rate is used to
account for the different industry mixes
in each state in order to accurately
reect the safety differences between
the states. Occupational fatalities
are measured over a three-year span
because of their low incidence rate. In
states where occupational fatality data is
not available for a specic industry, the
national rate for that industry was used
to calculate the states occupational
fatality rate. The 2012 ranks, based
on 2009 to preliminary 2011 occupa-
tional fatality data (Census of Fatal
Occupational Injuries, Bureau of Labor
Statistics, U.S. Department of Labor,
Washington, D.C.), are at www.ameri-
cashealthrankings.org/all/WorkFatalities.
The industry population data used to
calculate rates was based on 2010 data
collected by the Bureau of Economic
Analysis.
Table 15
Greatest Decreases in Children in Poverty (Change in the percentage of children in poverty)
Table 16
Greatest Increases in Children in Poverty (Change in the percentage of children in poverty)
LAST YEAR SINCE 2007 EDITION SINCE 2002 EDITION SINCE 1990 EDITION
STATE CHANGE STATE CHANGE STATE CHANGE STATE CHANGE
Mississippi -9.3 Mississippi & North Dakota (tie) -4.4 North Dakota -7.0 Mississippi -11.9
Oklahoma -4.3 Wyoming -2.3 Arkansas -2.1 Louisiana -8.0
North Dakota -4.2 Iowa -1.3 Alabama -1.4 Minnesota -7.9
Wisconsin +8.7 South Carolina +10.7 South Dakota +14.9 Delaware +13.7
South Dakota +7.1 Delaware +9.9 Delaware +13.5 Wisconsin +8.8
Montana +5.9 Indiana +9.3 Indiana +12.8 Oregon +7.9
Occupational fatalities represent
the impact of high risk jobs or unsafe
working conditions on the population.
Occupational injuries would be a pre-
ferred measure; however, there is not a
uniform reporting system used by all 50
states. Occupational fatalities represent
the most severe outcome from the work
environment and injuries incurred there.
These deaths contribute towards pre-
mature death as occupational fatalities
often occur in the prime of ones life.
Every year there are 5,600 occupational
fatalities as a result of an estimated
8.6 million occupational injuries.
74
The
estimated direct medical cost of these
injuries exceeds $46 billion.
75
The signif-
icant burden that occupational injuries
and fatalities place on the community
makes this area an excellent target for
interventions. Signicant progress has
been made in reducing the number of
occupational injuries and fatalities even
in the riskiest of occupations through
well documented measures such as
increasing safety precautions and
increased regulatory oversight.
76, 77
The number of occupational fatali-
ties varies from less than 3.0 deaths
per 100,000 workers in Massachusetts,
Minnesota, California, and Delaware
to over 8 deaths per 100,000 workers
in Alaska, Louisiana, Montana, and
New Mexico. The national rate is 4.1
deaths per 100,000 workers, essentially
unchanged from 4.0 deaths per 100,000
workers in the 2011 Edition.
Children in Poverty measures the
percentage of related persons under
age 18 living in a household that is
below the poverty threshold. The
poverty threshold established by the
U.S. Census Bureau for a household of
four people which includes two children
living in the lower 48 states is $22,811
in household income. The 2012 ranks,
based on 2011 data (Current Population
Survey, 2011 Annual Social and
Economic Supplement. Washington,
D.C., U.S. Census Bureau), are at
ChildPoverty.
The effect of poverty on health has
been clearly documented with higher
rates of many chronic diseases and
shorter life expectancy.
78, 79
Povertys
effect on more vulnerable popula-
Measures
74. Leigh JP. Economic burden of occupational injury and illness in the United States. Milbank Q.
2011;89(4):728-72.
75. Ibid.
76. Smith GS. Public health approaches to occupational injury prevention: Do they work? Injury Prevention.
2001; 7(90001):3i.
77. Herbert R. Work-related death: A continuing epidemic. Am J Public Health. 2000;90(4):541.
78. Fiscella K. Poverty or income inequality as predictor of mortality: longitudinal cohort study. BMJ. 314.7096
(1997):1724.
79. Adler NE, Ostrove JM. Socioeconomic status and health: What we know and what we dont. Ann N Y Acad
Sci. 1999;896(1):3-15.
tions such as children is even greater.
Poverty directly inuences a familys
ability to meet the basic needs of
their children including lack of access
to health care, limited availability of
healthy foods, constrained choices for
physical activity, and limited access to
educational opportunities. Children in
poverty are roughly three times more
likely to have unmet health needs than
other children.
80
Growing up in poverty
has many well documented negative
health effects from birth to adulthood.
Children born into poverty are more
likely than other children to be low
birthweight and die within the rst
month after birth.
81
As these children
grow up they are more likely to engage
in risky or unhealthy behaviors and are
at a greater lifetime risk of many dif-
ferent health problems.
82, 83
Due to the
increase in poor health found in children
in poverty, the estimated direct medical
cost of children in poverty is $22
billion.
84
Existing government programs
such as the Supplemental Nutrition
Assistance Program (SNAP) and Women
Infants and Children (WIC) are designed
to help alleviate some of the ill effects
of poverty. However, participation in
these programs is less than 100 percent
and other efforts are needed. There
are many other government programs
and community interventions that
have helped to reduce the number of
children in poverty as well as the burden
of poverty on children, yet poverty and
its negative effects on health persist
today.
The percentage of children in poverty
ranged from 8.6 percent of persons
under age 18 in New Hampshire to a
high of more than 30 percent in New
Mexico and Louisiana. The national
average is 21.4 percent, similar to last
years rate of 21.5 percent of children
and up 5.6 percent of children from the
low of 15.8 percent of persons under
age 18 reported in the 2002 Edition.
Infectious Disease measures the
combined incidence of measles, pertus-
sis, Hepatitis A, and syphilis per 100,000
population. Two-year averages are
used to calculate the incidence rates.
This was changed in the 2011 Edition
from previous editions, where infectious
disease was dened as the combined
incidence of AIDS, TB, and hepatitis A
and B, and three-year averages were
used. The 2012 ranks, based on 2009
and 2010 data (Mortality and Morbidity
Weekly Reports, Centers for Disease
Control and Prevention), are at www.
americashealthrankings.org/all/disease.
In the early 1900s, the eld of public
health was focused on combating
infectious diseases caused by poor sani-
tation and poor hygiene. Many great
achievements were made in this area
through vaccinations, antibiotics, and
education. It has only been since the
mid-1900s that the eld of public health
shifted its focus from infectious diseases
like cholera and smallpox to chronic
diseases like diabetes and cancer.
85
Despite the current focus on chronic
diseases, infectious diseases still pose a
threat and are responsible for a signi-
cant burden on our nations health. The
incidence of these infectious diseases
is an indication of the toll that largely
preventable diseases are placing on the
population. Infectious diseases pose a
threat to all members of a population,
but can be especially severe in young
children and the elderly, leading to
hospitalizations or even death.
86
The four diseases included in this
measure were chosen partially because
they represent different transmission
mechanisms and therefore different pre-
vention and treatment options. Measles
and pertussis are both airborne,
hepatitis A is generally spread through
food, and syphilis is sexually transmit-
ted. Transmission of measles, pertussis
and hepatitis A can be reduced through
vaccinations. The incidence of these
diseases provides information not only
about the immunization rate in a com-
munity but also information about the
ability of a system to prevent, detect,
and control outbreaks. Proper hand-
washing is a simple yet effective way to
prevent many infectious diseases includ-
ing hepatitis A, measles, and pertussis.
Safe cooking practices can prevent
most, if not all, foodborne infection
including hepatitis A. Condom usage
and other safe sex practices can help
prevent sexually transmitted diseases
such as syphilis. A high incidence of
infectious disease may be indicative
of a need for greater investment in
public health prevention measures.
Immunizations and early interventions
have proven effective in keeping infec-
tious disease rates at a minimum.
The incidence of infectious disease
per 100,000 population varies from a
reported low of 2.8 cases per 100,000
population in Vermont to a reported
high of 24.3 cases in Minnesota. The
national average is 12.4 cases per
100,000 population, an increase from
10.3 cases per 100,000 population
in 2011. Much of the increase in the
infectious disease rate is being driven
by a rise in pertussis cases across the
country, where the number of nation-
ally reported pertussis cases rose from
13,278 cases in 2008 to 16,858 in 2009
and 27,550 in 2010.
87
Air Pollution measures the ne
particulates in the air we breathe. It
is the population-weighted average
exposure to particulates 2.5 micron
80. Newacheck PW, Hughes DC, Hung YY, Wong S, Stoddard JJ. The unmet health needs of Americas chil-
dren. Pediatrics. 2000;105(4):989-97.
81. Moore KA. Children in poverty: Trends, consequences and policy options. Child Trends. 2002.
82. Lowry R. The effect of socioeconomic status on chronic disease risk behaviors among US adolescents.
JAMA. 1996;276(10):792.
83. Wood D. Effect of child and family poverty on child health in the United States. Pediatrics. 2003;112(suppl
3):707.
84. Holzer HJ, University of Wisconsin-Madison, Institute for Research on Poverty. The Economic Costs of
Poverty in the United States Subsequent Effects of Children Growing Up Poor. Madison, WI: Institute for
Research on Poverty; 2007.
85. Centers for Disease Control and Prevention (CDC). Achievements in public health, 1900-1999: Changes in
the public health system. MMWR - Morbidity & Mortality Weekly Report. December 24, 1999;48(50):1141-7.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4850a1.htm. Accessed September 24, 2012.
86. Armstrong GL. Trends in infectious disease mortality in the United States during the 20th century. JAMA.
1999;281(1):61.
87. Centers for Disease Control and Prevention (CDC). Pertussis (Whooping Cough). http://www.cdc.gov/
pertussis/surv-reporting.html. Accessed October 10, 2012.
and smaller for each county reporting
within a state. Air pollution is monitored
in many counties where population
density is signicant and/or where
there have been pollution concerns in
prior years. Population weighting of
the county data adjusts the information
to reect the actual number of people
potentially exposed to particulates. In
counties where pollution data is not
available, the population was assumed
to be exposed to the background level
of particulates in the air quality control
region and/or state. Background levels
are estimated to be the average of the
lowest measures in each region or state
for each of the last three years. The
2012 ranks, based on 2009 to 2011 data
(U.S. Environmental Protection Agency,
Washington, D.C. and the U.S. Census
Bureau, Washington, D.C.), are at www.
americashealthrankings.org/all/air.
Air pollution is an important aspect
of the physical environment that has
an impact on health. Air pollution is
widespread, affects a large number of
people, and can have very severe health
effects. Young children and older adults
are especially at risk of adverse effects
from air pollution.
88, 89
Fine particulates
found in smoke or haze are able to pen-
etrate deeply into lungs and have been
shown to increase premature death in
people suffering from heart disease
and lung disease.
90, 91
Exposure has also
been linked to increased respiratory
symptoms, decreased lung function,
asthma, chronic bronchitis, irregular
heartbeats, and heart attacks.
92
Current
estimates put the number of deaths
resulting from air pollution at around
24,000 annually.
93
Other adverse effects
on health from air pollution include
decreased lung function, asthma
aggravation, chronic bronchitis, irregular
heartbeat, and heart attacks. See www.
epa.gov/air/particlepollution/health.
html for more information. The extent
of air pollution has decreased in recent
years, but in some areas pollution levels
are still quite high. Individuals can
reduce their contributions to air pollu-
tion by reducing fossil fuel consumption
and wood burning. Individuals can
also reduce their risk of adverse health
effects by monitoring air quality at www.
airnow.gov.
Air pollution varies from a low of 5.1
micrograms of ne particulate per cubic
meter in Wyoming to 15.3 micrograms
of ne particulate per cubic meter in
California. The national average is 10.5
micrograms of ne particulate per cubic
meter, down slightly from 10.8 micro-
grams in the 2011 Edition and 12.2
micrograms in the 2007 Edition.
Three measures are used to repre-
sent public and health policies and
programs: public health funding,
immunization coverage, and lack of
health insurance. These measures are
indicative of the availability of resources
and the extent of the programs reach to
the public.
Every state has many excellent and
effective public health programs, too
numerous and individualized to list,
that contribute to the overall health of
the population but are not explicitly
included in these rankings. Contact
your state public health ofcials to
obtain additional information about
programs in your state that are enacted
to optimize individual and community
health. Each states health department
website is listed on the corresponding
state snapshot. Individuals can also see
the spectrum of options available to
states and communities by visiting www.
thecommunityguide.org, a website that
provides a systemic review of programs
and evidence-based recommendations
for health and community ofcials.
Lack of Health Insurance measures
the percentage of the population not
covered by private or public health
insurance. The 2012 ranks, based on
2010 and 2011 data (Current Population
Survey, 2008 to 2011 Annual Social and
Economic Supplements, Washington,
D.C., U.S. Census Bureau), are at www.
americashealthrankings.org/all/2012/
insurance.
Individuals without health insurance
have more difculty accessing the
health care system, are often unable to
participate in preventive care programs,
and have more unmet health needs.
94
In addition to decreasing quality of life,
these unmet health needs can place
a substantial burden on the health
care system. Unmet health needs can
over time develop into more serious
conditions which require more costly
treatments. A lack of health insurance
often leads to more emergency depart-
ment visits due to a lack of access
elsewhere. Treatment in the emergency
department can cost up to ten times
more than treatment in a clinic.
95
For
Table 17
Greatest Decreases in Lack of Health Insurance
(Change in percentage of people uninsured)
LAST YEAR SINCE 2007 EDITION
STATE CHANGE STATE CHANGE
Oregon -1.9% Massachusetts -5.3%
Alabama -1.6% Utah -2.7%
Delaware -1.4% Colorado -2.6%
Measures
88. Bates DV. The effects of air pollution on children. Environ Health Perspect. 1995;103:49-53.
89. Sarnat SE. Ambient particulate air pollution and cardiac arrhythmia in a panel of older adults in
Steubenville, Ohio. Occup Environ Med. 2006;63(10):700.
90. Pope CA 3rd. Epidemiology of ne particulate air pollution and human health: Biologic mechanisms and
whos at risk? Environ Health Perspect. 2000;108:713-23.
91. Dominici F. Revised analyses of the national morbidity, mortality, and air pollution study: Mortality among
residents of 90 cities. Journal of Toxicology and Environmental Health. Part A. 2005;68(13-14):1071.
92. Peters A. Increased particulate air pollution and the triggering of myocardial infarction. Circulation.
2001;103(23):2810.
93. Mokdad AH. Actual causes of death in the United States, 2000. JAMA. 2004;291(10):1238.
94. Ayanian JZ. Unmet health needs of uninsured adults in the United States. JAMA. 2000;284(16):2061.
95. Newton MF. Uninsured adults presenting to US emergency departments. JAMA. 2008;300(16):1914.
these reasons and many more, unin-
sured individuals have consistently been
found to have worse health outcomes.
96
Among the uninsured, preventative
health care services are less utilized
and cancer mortality rates are higher.
97
Overall, the unmet health needs of the
uninsured translate into a 25 percent
greater risk of mortality compared to
those with insurance, accounting for
an estimated 18,000 excess deaths
annually.
98
The rate of uninsured popula-
tion ranges from 4.5 percent in
Massachusetts to 24.2 percent in Texas.
The national average of uninsured
population is 16.0 percent (nearly 50
million adults) uninsured.
Public Health Funding measures the
dollars per person that are spent on
public or population health through
funding from the Centers for Disease
Control and Prevention, Health
Resources Services Administration,
and the state. This does not include
spending from other sources such as
county or city governments, nor does
it include state spending for health
that is included under other depart-
mental spending such as education
and transportation. The 2012 ranks,
based on 2010 and 2011 data (Trust for
Americas Health, Washington, D.C.),
are at www.americashealthrankings.org/
all/PH_Spending.
High levels of spending on public
health programs are indicative of states
that are proactively implementing
preventive and education programs
aimed at improving health. Spending
on public health programs represents
only a small fraction of all health care
spending (~ 2 percent), yet its impact
can be tremendous.
99
Recent research
has shown that an investment of $10 per
person per year in proven community-
based programs to increase physical
activity, improve nutrition, and prevent
smoking or other tobacco use could
save the country more than $16 billion
annually within ve years. This is a
return of $5.60 for every $1 invested.
100
Public health funding that contributes
to behavioral or environmental
interventions has the potential to
contribute more towards improving
health than funding spent on medical
care. Increased spending on public
health programs is associated with a
decrease in mortality from preventable
causes of death.
101
The Trust for
Americas Health released a report on
the current state of the public health
system with many recommendations
for improvement.
102
The report can be
found at healthyamericans.org/assets/
les/Blueprint.pdf.
Public health funding ranges from
$200 or more per person in Alaska and
Hawaii to less than $40 per person in
Nevada and Wisconsin. The average
funding in the United States is $92 per
person, a decrease from $95 in last
years edition.
Immunization Coverage is the
average of the percentage of children
ages 19 to 35 months who have
received the following vaccines:
Diphtheria, Tetanus, Pertussis (DTP),
Poliovirus, Measles, Mumps, & Rubella
(MMR) and Hepatitis B Vaccine (HepB).
This measure does not account for
each individual receiving the full
series of shots, but rather, individuals
receiving individual shots. The 2012
ranks, based on 2011 data (National
Immunization Program, Centers for
Disease Control and Prevention), are at
immunize.
Early childhood immunization has
been shown to be a safe and cost-
effective means of controlling diseases
within the population. In the last 50
years, vaccinations have led to a 95
percent decrease in vaccine prevent-
able diseases.
103
The CDC recently
called vaccines one of the ten greatest
public health achievements of the 20th
century. Routine childhood immuniza-
tions are estimated to save almost
$10 billion in direct medical costs.
104
The Guide to Community Preventive
Services has numerous proven methods
to increase the rate of vaccinations
in a community that include ways to
increase the demand in the community,
improve access, and system-based or
provider-based innovations.
105
See their
suggestions at www.thecommunityguide.
org/vaccines/universally/index.html.
Immunization coverage ranges from
94.2 percent of children ages 19 to 35
months in Nebraska to 82.5 percent
in Wyoming. In the United States, the
average immunization coverage is
90.3 percent of children ages 19 to 35
months, the same coverage as last year.
CLINICAL CARE
Clinical care has the potential to enable
people to live longer and healthier by
treating and managing existing condi-
tions and preventing others. Preventive
and curative care must be delivered
in an appropriate and timely manner
in order for it to be most effective.
Three measures are included in this
section: Low Birthweight, Primary
Care Physicians, and Preventable
Hospitalizations. These clinical care
measures provide information about the
96. Freeman JD. The causal effect of health insurance on utilization and outcomes in adults: A systematic
review of US studies. Med Care. 2008;46(10):1023.
97. Ward E. Association of insurance with cancer care utilization and outcomes. Ca. 2008;58(1):9.
98. Ayanian JZ. Unmet health needs of uninsured adults in the United States. JAMA. 2000;284(16):2061.
99. Levi J, Segal LM, Juliano C. Prevention for a Healthier America: Investments in Disease Prevention Yield
Signicant Savings, Stronger Communities. Washington, DC: Trust for Americas Health; July 2008.http://
healthyamericans.org/reports/prevention08/Prevention08.pdf. Accessed August 3, 2012.
100. Trust for Americas Health. Prevention for a Healthier America: Investment in Disease Prevention Yield
Signicant Savings, Stronger Communities. 2011.
101. Mays, GP. Evidence links increases in public health spending to declines in preventable deaths. Health
Affairs. 30.8 (2011):1585.
102. Trust for Americas Health. Blueprint for a Healthier America: Modernizing the Federal Public Health
System to Focus on Prevention and Preparedness. October 2008. http://healthyamericans.org/assets/
les/Blueprint.pdf. Accessed August 6, 2012.
103. Shefer A, Briss P, Rodewald L, et al. Improving immunization coverage rates: An evidence-based review
of the literature. Epidemiol Rev. 1999;21(1):96-142.
104. Zhou F. Economic evaluation of the 7-vaccine routine childhood immunization schedule in the United
States, 2001. Archives of Pediatrics Adolescent Medicine. 2005;159(12):1136.
105. Guide to Community Preventive Services. Vaccinations to prevent diseases: universally recommended
vaccinations. May 2012. www.thecommunityguide.org/vaccines/universally/index.html. Accessed August
6, 2012.
availability, utilization, and efcacy of
clinical care.
Low Birthweight is the percentage of
live births born weighing less than 2,500
grams (5 pounds, 8 ounces). Low birth-
weight was changed in this edition from
a supplemental measure to a clinical
care measure to be used as a proxy for
clinical care during the prenatal period.
Unlike the previously included early
prenatal care measure, direct state-to-
state comparisons can be made and
a national average can be calculated
using the low birthweight data. The
2012 ranks are based on 2010 birth cer-
ticates from the National Vital Statistics
System, NCHS, CDC. This is a two-year
jump in the data as the supplemental
data included in the 2011 Edition was
based on 2008 birth data.
Babies born with low birthweight
are often born preterm or have inad-
equate growth for other reasons. Low
birthweight may occur as a result of
inadequate clinical care in the prenatal
period. Through regular clinical visits,
the health of the mother can be
assessed, health risks can be identi-
ed, and steps can be taken to improve
the mothers health. Low birthweight
is associated with many characteristics
of the mother such as smoking status,
nutritional status, and psychosocial
problems.
In addition to being an indicator of
the mothers health and clinical care, low
birthweight is itself a potential cause
of future health problems for the baby.
Low birthweight babies are more likely
than babies of normal weight to have
health problems during the newborn
period. Serious medical problems are
most common in babies born at very
low birthweight and include respira-
tory distress syndrome; bleeding in the
brain; patent ductus arteriosus, a heart
problem common in premature babies;
necrotizing enterocolitis, an intestinal
problem that usually develops two to
three weeks after birth; and retinopathy
of prematurity, an abnormal growth of
blood vessels in the eye that can lead
to vision loss.
106, 107
There may also be
a connection between many chronic
diseases in adulthood and low birth-
weight, including type 2 diabetes and
coronary heart disease.
108
Successful
prevention strategies address these
characteristics by:
109
Exponding occess ro medicol ond
dental services and taking a lifespan
approach to health care
Focusing inrensively on smo|ing
prevention and cessation
Ensuring r|or pregnonr women ger
adequate nutrition
Addressing demogrop|ic, sociol, ond
environmental risk factors
Fewer r|on percenr ol 6o6ies ore
6orn wir| low 6irr|weig|r in Alos|o
while more than 10 percent are born
with low birthweight in Mississippi,
Louisiono, ond Alo6omo. Norionolly,
8.1 percent of babies are born with low
birthweight.
Primary Care Physicians is a measure
of access to primary care for the
general population as measured by
number of primary care physicians
per 100,000 population. Primary
care physicians include all those who
idenrily r|emselves os Fomily Frocrice
physicians, General Practitioners,
Internists, Pediatricians, Obstetricians,
or Gynecologists. The 2012 ranks,
6osed on 2010 doro (Americon Medicol
Associorion, F|ysicion C|orocrerisrics
and Distribution in the United States,
2012 Edition, Chicago, Ill. Data
used with permission), are at www.
americashealthrankings.org/all/PCP.
The number of primary care physi-
cians is a measure of the availability
of health care. Primary care physi-
cians provide direct patient care and,
as necessary, counsel patients in the
appropriate use of specialists and
advanced treatment options. Primary
care physicians are often the rst point
of contact with the health care system
for patients and provide critical preven-
tative care, ongoing care, and referrals
to specialists. The availability of primary
care physicians has a documented
inuence on health, as greater numbers
of primary care physicians have been
linked to better health outcomes includ-
ing lower rates of low birthweight,
lower all cause mortality, and longer
life spans.
110
The number of primary
care physicians per 100,000 people is
constantly changing due to evolving
state populations, physician retirements,
new physicians, and physicians moving
between states and specialties.
Primary care physicians range from
195 physicians per 100,000 popula-
tion in Massachusetts to 78 physicians
per 100,000 in Idaho. The national
average is 120 primary care physicians
per 100,000 population, essentially
unchanged in the last few years.
Preventable Hospitalizations is
a measure of the discharge rate of
Medicare enrollees ages 65 to 99
wir| lull Forr A enrirlemenr ond no
HMO enrollment from hospitals for
ambulatory care-sensitive conditions.
Am6ulorory coresensirive condirions
are those for which good outpatient
care can potentially prevent the need
for hospitalization, or for which early
intervention can prevent complica-
tions or more severe disease.
111
These
conditions are based on ICD-9-CM
diagnosis codes and include: convul-
sions, chronic obstructive pulmonary
disease (COPD), bacterial pneumo-
nia, asthma, congestive heart failure
(CHF), |yperrension, ongino, celluli-
tis, diabetes, gastroenteritis, kidney/
urinary infection, and dehydration. The
Measures
106. Lemons JA, Bauer CR, Oh W, et al. Very low birth weight outcomes of the National Institute of Child
Health and Human Development Neonatal Research Network, January 1995 through December 1996.
NICHD Neonatal Research Network. Pediatrics. 2001;107(1).
107. Als H. Individualized developmental care for the very low-birth-weight preterm infant. JAMA.
1994;272(11):853.
108. Barker DJP. Fetal origins of adult disease: Strength of effects and biological basis. Int J Epidemiol.
2002;31(6):1235.
109. Shore R, Shore B. Preventing Low Birthweight. KIDS COUNT Indicator Brief. Annie E. Casey Foundation.
2009 http://www.aecf.org/KnowledgeCenter/Publications.aspx?pubguid=%7B950E85EE-C2B4-466E-
AA20-AE2010384A17%7D
110. Stareld B. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457.
111. Agency for Health Care Research and Quality. Prevention Quality Indicators Overview. http://www.quality-
indicators.ahrq.gov/. Updated 2003. Accessed August 3, 2012.
2012 ranks, based on 2010 data (The
Dartmouth Atlas of Health Care, The
Dartmouth Institute for Health Policy
and Clinic Practice, Lebanon, N.H.), are
at www.americashealthrankings.org/all/
preventable.
Preventable hospitalizations reect
how efciently a population uses the
various health care delivery options
for necessary care. Hospital care is
expensive and makes up the largest
component of health care spending in
the U.S., totaling over $750 billion.
112
Preventable hospitalizations often occur
as a result of a failure to treat conditions
early in an outpatient setting due to
limited availability.
113
These discharges
are also highly correlated with general
admissions and reect the tendency for
a population to overuse the hospital
setting as a site for care. Preventable
hospitalizations place a nancial burden
on heath care systems as they could
have been avoided with earlier less
costly interventions. Preventable hospi-
talizations are more common in those
who are uninsured, which often leads to
large unpaid medical bills.
114
The rate of preventable hospital-
izations ranges from a low of under
40 discharges per 1,000 Medicare
enrollees in Hawaii and Utah to 103 dis-
charges per 1,000 Medicare enrollees
in Kentucky. The national average is 67
discharges per 1,000 Medicare enroll-
ees, down slightly from 68.2 discharges
last year and 78.4 in the 2007 Edition.
HEALTH OUTCOMES
Health outcomes include the prevalence
of adults with diabetes, quality of life,
mortality rates, and the variation among
mortality in a state. These measures
represent the burden placed on the
overall health of a population by chronic
disease, death, disparity, and depressed
quality of life. Measures range from
counting days in which people feel their
normal activities are limited due to poor
health to disease-specic mortality and
years of potential life lost.
Outcomes are traditionally measured
using mortality measures which include
premature death, infant mortality,
cancer, and cardiovascular mortality.
While these measures overlap signi-
cantly, they do present different views of
mortality outcomes of a population.
Diabetes is the percentage of
adults who have been told by a health
professional that they have diabetes,
excluding pre-diabetes and gestational
diabetes. Diabetes was changed in
the 2011 Edition from a supplemental
measure to an outcome measure to
account for the impact of treating and
managing chronic diseases in the U.S.
The 2012 ranks, based on self-report
data from CDCs 2011 BRFSS data, are
diabetes. The BRFSS telephone survey
people using landlines. During the
Because of these changes, estimates
of diabetes prevalence from the 2012
percentages.
Diabetes is often an outcome of
an unhealthy lifestyle and increases
ones risk of developing many other
diseases and complications. There are
three major types of diabetes: type 1
diabetes, type 2 diabetes, and ges-
tational diabetes. Of these, type 2
diabetes accounts for 90 to 95 percent
of all cases. Type 2 diabetes is a largely
preventable progressive disease that
is managed through lifestyle modica-
tions and health care interventions. It
is a major cause of heart disease and
stroke as well as the leading cause of
kidney failure, non-traumatic lower-limb
amputations, and blindness in adults.
115
Overall it is the seventh leading cause
of death in the U.S. and contributes
to the rst and third leading causes of
death, stroke and heart disease respec-
tively.
116
Direct medical costs for type
2 diabetes exceed $100 billion and
account for $1 of every $10 spent on
medical care in the U.S.
117
Studies have shown that the onset
of type 2 diabetes can be prevented
through weight loss, increasing
physical activity, and improving dietary
choices.
118, 119
Type 2 diabetes is
associated with numerous modiable
risk factors such as smoking, obesity,
physical activity, and diet which make
it an ideal target for prevention.
120
The
National Diabetes Prevention Program
was created to bring evidence-based
interventions to prevent diabetes to
communities across the country. More
information on prevention is available
at www.cdc.gov/diabetes/projects/
prevention_program.htm. Additional
diabetes information is available at the
National Center for Chronic Disease
Prevention and Health Promotion, CDC
(www.cdc.gov/diabetes/ and www.cdc.
gov/nccdphp/publications/aag/ddt.htm)
and the American Diabetes Association
(www.diabetes.org/).
The percentage of adults with
diabetes ranges from 12.0 percent or
more of the population in West Virginia,
South Carolina, and Mississippi to less
than 7.0 percent in Colorado and Utah.
112. The Kaiser Family Foundation. Trends in Health Care Costs and Spending. 2009;7692-02.
113. Billings J. Recent ndings on preventable hospitalizations. Health Aff. 1996;15(3):239.
114. Weissman JS. Rates of avoidable hospitalization by insurance status in Massachusetts and Maryland.
JAMA. 1992;268(17):2388.
115. Centers for Disease Control and Prevention (CDC). National Diabetes Fact Sheet: National Estimates and
General Information on Diabetes and Prediabetes in the United States, 2011.
116. Heron M. Deaths: Leading causes for 2007. National Vital Statistics Reports; vol 59, no 8. Hyattsville, MD:
National Center for Health Statistics. 2011.
117. American Diabetes Association. Economic costs of diabetes in the U.S. in 2007. Diabetes Care.
2008;31(3):596-615.
118. Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with
lifestyle intervention or metformin. N Engl J Med. 2002;346(6):393-403.
119. Tuomilehto J. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired
glucose tolerance. N Engl J Med. 2001;344(18):1343.
120. Schulze MB. Primary prevention of diabetes: What can be done and how much can be prevented? Annu
Rev Public Health. 2005;26(1):445.
The national median of adults with
diabetes is 9.5 percent.
Poor Mental Health Days is the
average number of days in the previous
30 days that a person could not perform
work or household tasks due to mental
illness. The self-reported data relies
on the accuracy of each respondents
estimate of the number of limited
activity days they experienced in the
previous 30 days. The 2012 ranks,
based on 2011 data (Behavioral Risk
Factor Surveillance System, Centers for
Disease Control and Prevention), are
at www.americashealthrankings.org/
all/MentalDays. The BRFSS telephone
by people using landlines. During the
Because of these changes, estimates of
poor mental health days from the 2012
percentages.
Poor mental health days provide a
general indication of health related
quality of life, mental distress, and
the burden that more serious mental
illnesses place on the population.
Good mental health is essential to
good overall health and wellness. Poor
mental health days are an assessment
of the impact of poor mental health on
wellness. The number of poor mental
health days is also a predictor of future
health as it predicts 1-month and
12-month ofce visits and hospitaliza-
tions.
121
In extreme cases, poor mental
health can lead to suicide, which is
the 11th leading cause of death for
all ages and the 2nd leading cause of
death among 25 to 34 year olds. The
medical costs of mental illness are
estimated to be approximately $100
billion annually.
122
Although occasional
short periods of mental distress and
a few poor mental health days may
be unavoidable, more prolonged and
serious episodes are treatable and pre-
ventable though early interventions.
123
The number of poor mental health
days in the previous 30 days ranges
from an average of 2.8 days in Hawaii
and North Dakota to 5.2 days in
Arkansas. The average number of poor
mental health days in the previous 30
days for the United States is 3.8 days.
Poor Physical Health Days is the
average number of days in the previous
30 days that a person could not perform
work or household tasks due to physical
illness. The self-reported data relies
on the accuracy of each respondents
estimate of the number of limited
activity days they experienced in the
previous 30 days. The 2012 ranks,
based on 2011 data (Behavioral Risk
Factor Surveillance System, Centers for
all/PhysicalDays. The BRFSS telephone
by people using landlines. During the
Because of these changes, estimates of
poor physical health days from the 2012
percentages.
Poor physical health days are a
general indicator of the populations
health related quality of life. The
number of poor physical health days
reveals information about all cause
morbidity within the population regard-
less of the disease or health condition.
Along with poor mental health days, it
provides insight into perceived overall
health. Poor physical health is not only
an indicator of current health status but
a predictor of future health and future
medical care; it has been shown to be
a predictor of 1-month and 12-month
hospitalizations and ofce visits.
124
The number of poor physical
health days in the previous 30 days
ranges from an average of 2.9 days in
Minnesota to 5.3 days in West Virginia.
The average number of poor physical
health days in the previous 30 days for
the United States is 3.9 days.
Geographic Disparity measures the
variation in the age-adjusted mortality
rate among counties within a state. It
is the standard deviation of the three-
year average, age-adjusted all-cause
mortality rate for all counties within
a state divided by the three-year
age-adjusted all-cause mortality rate
for the state. The lower the percent,
the closer each county is to the state
average and the more uniform the
mortality rate is across the state. For
counties with fewer than 20 deaths
in the three-year period (about 20 to
30 counties in the United States each
year), the county was assumed to have
an age-adjusted death rate equal to
the states age-adjusted death rate and
thus has no effect on the geographic
disparity of the state. Geographic
Disparity was a new measure in the
2008 Edition. The 2012 ranks, based on
2007 to 2009 data (National Center for
Health Statistics. Centers for Disease
Control and Prevention), are at www.
americashealthrankings.org/all/disparity.
Ideally, health and mortality should
be equal among the populations of
every county within a state and not vary
based upon where a person lives. Many
factors differ among counties, includ-
ing natural features such as altitude,
latitude, moisture, and temperature,
and man-made features such as land
Measures
121. Dominick KL, Ahern FM, Gold CH, Heller DA. Relationship of health-related quality of life to health care
utilization and mortality among older adults. Aging Clin Exp Res. 2002;14:499-508.
122. Mark TL, Levit KR, Buck JA, Coffey RM, Vandivort-Warren R. Mental health treatment expenditure trends,
1986 2003. Psychiatric Services. 2007;58:10411048.
123. Moriarty DG. Geographic patterns of frequent mental distress: US adults, 19932001 and 20032006. Am
J Prev Med. 2009;36(6):497.
124. Dominick KL, Ahern FM, Gold CH, Heller DA: Relationship of health-related quality of life to health care
utilization and mortality among older adults. Aging Clin Exp Res. 2002;14:499-508.
Table 18
Greatest Decreases in Infant Mortality (Change is number of fewer
deaths within the rst year of life per 1,000 live births)
Alabama -0.8 Tennessee -1.4 South Carolina -1.9 South Carolina -5.4
Nebraska, South Carolina and Wyoming (tie) -0.7 Delaware and South Carolina (tie) -1.3 Hawaii -1.8 New York -5.3
Idaho, North Dakota, and Rhode Island (tie) -0.6 Nebraska -1.1 Nebraska -1.7 Idaho -5.1
use, population density, roads, and
communications. Yet even with these
differences health should still be equal.
In many states there are disparities
between urban and rural settings, with
better health outcomes found in urban
areas. Residents of rural areas are more
likely to report fair or poor health,
less likely to meet recommendations
for physical activity and less likely to
receive preventative care than their
urban counterparts.
125
Poor access to
health care plagues many rural areas in
the U.S. as 77 percent of rural counties
are designated as primary care health
professional shortage areas.
126
This
measure indicates the health toll of dif-
ferences in behaviors, access to health
care, and the physical environment
within a state. Uncovering inequities
in mortality can help states to identify
regions with particularly poor outcomes
and allocate resources accordingly.
Geographic disparity varies from a
low geographic disparity of less than
6.0 percent in Vermont and Rhode
Island to a high geographic disparity
of more than 25 percent in Alaska and
South Dakota. For the United States
as a whole, the geographic disparity
among all counties is 17.9 percent, a
slight increase from 17.2 percent in the
2011 Edition.
Infant Mortality measures the number
of infant deaths that occur before age
1 per 1,000 live births. The 2012 ranks,
based on a two-year average using
2008 and 2009 data (National Center
for Health Statistics, Washington, D.C.),
are at www.americashealthrankings.org/
all/IMR.
Infant mortality is associated with
many factors surrounding birth, includ-
ing but not limited to: maternal health,
prenatal care, and access to quality
healthcare.
127
Congenital malformations
are the leading cause of infant mortality
followed closely by disorders related to
preterm birth and low birthweight.
128
Infant mortality is commonly used to
compare health between different
countries because of its association with
access to health care in the prenatal
period and rst year of life. The nations
overall infant mortality rate is consis-
tently higher than other developed
countries, and signicant racial and
ethnic disparities exist.
129
The demo-
graphics of the mother are important
predictors of infant mortality, with
minority women and low socioeconomic
status women having the highest rates.
In addition to the demographic factors,
there are also many health care system
factors that inuence infant mortality.
Improving access to and utilization of
ongoing prenatal care is a key strategy
towards decreasing infant mortality, as
well as reducing the teen birth rate and
maternal smoking. The U.S. Department
of Health and Human Services has put
together a fact sheet on preventing
infant mortality at www.hhs.gov/news/
factsheet/infant.html.
Infant mortality varies greatly among
states, from less than 5.0 deaths per
1,000 live births in New Hampshire
to 10.0 deaths per 1,000 live births in
Mississippi. The national average is
6.5 deaths per 1,000 live births, a 0.5
reduction since the 2002 Edition. States
with a low number of births will experi-
ence more uctuations in the two-year
average infant mortality rate than states
with a higher number of births.
Cardiovascular Deaths measures
the three-year average, age-adjusted
number of deaths attributed to cardio-
vascular diseases, including but not
limited to heart disease and stroke, per
100,000 population. The 2012 ranks,
based on 2007 to 2009 data (National
Center for Health Statistics, Centers for
all/CVD. The rates are age-adjusted
using NCHSs bridged-race estimates
of the July 1 resident population from
the 2008 county-level postcensal series.
The following ICD-10 codes were used
in our denition: I10-I15 (Hypertensive
diseases), I20-I25 (Ischaemic heart
diseases), I26-I28 (Pulmonary heart
disease and diseases of pulmonary
circulation), I30-I51 (other forms of
heart disease), I60-I69 (cerebrovas-
cular diseases), I70-I78 (Diseases of
125. Bennett K, Olatosi B, Probost J. Health Disparities: A Rural-Urban Chart Book. Rural Health Research and
Policy Centre; 2008.
126. Mareck, DG. Federal and State Initiatives to Recruit Physicians to Rural Areas. The virtual mentor 13.5
(2011):304.
127. Singh GK, Yu SM. Infant mortality in the United States: Trends, differentials, and projections, 1950 through
2010. Am J Public Health. 1995;85(7):957-964.
128. Mathews TJ. Infant mortality statistics from the 2006 period linked birth/infant death data set. National
Vital Statistics Reports. 2010;58(17):1.
129. MacDorman MF, and Mathews TJ. Recent Trends in Infant Mortality in the United States. Hyattsville, MD:
US Dept. of Health and Human Services, Centers for Disease Control and Prevention, National Center for
Health Statistics; 2008.
arteries, arterioles, and capillaries),
I80-I89 (Diseases of veins, lymphatic
vessels and lymph nodes, not elsewhere
classied), and I 95-I99 (Other and
unspecied disorders of the circulatory
system).
Cardiovascular deaths are an indi-
cation of the toll that cardiovascular
disease places on the population. In the
United States, heart disease and stroke
are currently the leading and fourth
leading causes of death, respectively.
130
Cardiovascular disease accounts for
17 percent of medical spending and
30 percent of Medicare spending; it
totals nearly $150 billion annually.
131
Cardiovascular disease is inuenced
by a long list of modiable risk factors:
smoking, hypertension, hypercholester-
olemia, diabetes, low levels of physical
activity, poor diet, and obesity.
132
Inuencing one or more of these risk
factors has the potential to greatly
decrease the burden of cardiovascu-
lar disease. An initiative to reduce this
burden, Million Hearts, aims to prevent
one million heart attacks and strokes by
2017.
133
Additional information on the
initiative is available at millionhearts.hhs.
gov/.
Deaths from cardiovascular disease
vary from a low of 195.9 deaths per
100,000 population in Minnesota to
357.4 deaths per 100,000 population
in Mississippi. The national average is
264.9 deaths per 100,000 population,
down from 270.4 deaths per 100,000
population last year and 405.1 deaths
per 100,000 population in 1990. The use
of mortality data does not reect the full
burden of cardiovascular disease on the
nation, as data indicates that despite
declining cardiovascular mortality rates,
more individuals are living with cardiac
disease as new procedures prolong the
lives of these individuals.
Cancer Deaths measures the three-
year average, age-adjusted number
of deaths attributed to cancer per
100,000 population. The 2012 ranks,
based on 2007 to 2009 data (National
Center for Health Statistics. Centers for
all/cancer. The rates are age-adjusted
using NCHSs bridged-race estimates
of the July 1 resident population from
the 2008 county-level postcensal series.
The following ICD-10 codes were
used: C00-C97 (Malignant neoplasms),
D00-D09 (In situ neoplasms), and
D37-D48 (Neoplasms of uncertain or
unknown behavior).
Cancer is the second leading cause
of death in the United States, and the
Measures
North Dakota -13.3 Louisiana -19.0 New Jersey -27.9 Maryland -34.2
Mississippi -11.3 Utah -18.4 Rhode Island -25.6 New York -33.6
New Jersey -10.4 Arizona -17.8 New York and Utah (tie) -25.5 New Jersey -31.1
South Carolina -9.9 Georgia -17.5 Delaware -25.1 California -28.8
Montana and -9.8 Nevada and -17.1 Maryland -24.9 Nevada -27.5
South Dakota (tie) New Jersey (tie)
Table 19
Greatest Decreases in Cardiovascular Deaths (Change is number of fewer deaths per 100,000 population)
California -11.6 Tennessee -57.1 South Carolina -102.6 South Carolina -182.5
Nevada -10.6 Oklahoma -54.3 Georgia -93.9 Vermont -171.2
Mississippi -9.0 Georgia -54.1 Kentucky -90.0 Maine -168.8
Florida -8.5 y Kentucky -52.6 Florida -88.3 y New Jersey -164.7
Arizona and Virginia (tie)-8.0 Florida -52.5 Tennessee -86.3 Delaware -164.3
Table 20
Greatest Decreases in Cancer Deaths (Change is number of fewer deaths per 100,000 population)
130. Murphy SL, Xu J, Kochanek KD. Deaths: preliminary data for 2010. National Vital Statistics Reports.
2012;60(4):1-69.
131. Trogdon, JG, Finkelstein EA, Nwaise IA, Tangka FK, and Orenstein D. The economic burden of chronic
cardiovascular disease for major insurers. Health Promotion Practice. 8.3 (2007): 234-42. Print.
132. Jackson, R. Guidelines on preventing cardiovascular disease in clinical practice. BMJ : J British Medical
Journal. 320.7236 (2000): 659. Print.
133. Frieden TR, Berwick DM. (2011). The Million Hearts initiative preventing heart attacks and strokes.
N Engl J Med, 365(13), e27. doi:10.1056/NEJMp1110421.
cancer death measure is an indication
of the toll it places on the population.
134
Cancer kills over a half million people
each year and costs over $48 billion
in direct medical costs.
135
Signicant
opportunities exist to reduce the risk
of developing some cancers and to
prevent others. The CDC estimates
that one third of all cancer deaths are
attributable to tobacco use and another
third are attributable to poor nutrition,
physical inactivity, and obesity.
136
Other
types of cancer such as colon and
cervical may be preventable through
vaccinations, screening, or early
detection. More information on the
cancer burden in the U.S. is available at
www.cdc.gov/chronicdisease/resources/
publications/AAG/dcpc.htm.
The rate varies from 128.6 cancer
deaths per 100,000 population in Utah
to 215.7 deaths per 100,000 popula-
tion in Kentucky. The national average
is 182.5 deaths per 100,000 population,
a decrease of 8.3 deaths per 100,000
population from the 2011 Edition and a
decrease of only 15 deaths per 100,000
population from the 1990 Edition.
Cancer deaths peaked in 1996 when
the national rate was 205.5 deaths per
100,000 population.
Premature Death measures the loss
of years of life due to death before
age 75 as dened by the Centers
for Disease Control and Preventions
Years of Potential Life Lost (YPLL-
75). Thus, the death of a 25-year-old
would account for 50 years of lost
life, while the death of a 60-year-old
would account for 15 years. The 2012
Table 21
Greatest Decreases in Premature Death
(Change is number of fewer years lost before age 75 per 100,000 population)
Wyoming -420 Arizona -592 New York -797 New York -3571
New Mexico -405 Louisiana -540 New Jersey -770 New Jersey -2550
Vermont -150 South Dakota -416 Illinois -711 California -2263
Delaware -107 Maryland -378 Maryland -643 Vermont -2130
Florida -71 South Carolina -348 South Dakota -641 Georgia -1811
Supplemental Measures
The core measures used in the
Rankings represent a small fraction of
the measures available to the general
public and to public health ofcials. The
website
contains supplemental measures that
are useful in understanding the health
of your state and provide information
for more in-depth analysis.
Table 22 on page ppp contains a
brief denition of the supplemental
measures including the source and data
year for each measure.
ranks, based on 2009 data (National
Center for Health Statistics. Centers for
Disease Control and Prevention), are at
www.americashealthrankings.org/ALL/
PrematureDeath.
Premature death is a measure of
mortality that reects the age of death
for persons under 75 years of age. A
person who dies very young contrib-
utes more towards the overall measure
and causes it to increase more than
someone who dies closer to 75. Deaths
occurring in younger people are more
likely to be preventable than those
occurring in older people and are indic-
ative of failures in the health care system
and/or lifestyle factors. According to
2009 mortality data, cancer, uninten-
tional injury, heart disease, suicide and
deaths occurring during the perinatal
period are the top ve causes of prema-
ture death in the United States.
137
Many
of these causes of death are prevent-
able through lifestyle modications.
Lung cancer is the largest contributor
towards premature cancer deaths, and
smoking cessation can greatly decrease
the risk of lung cancer. Heart disease is
tied to several modiable risk factors
such as obesity, diabetes, and sedentary
lifestyle. A variety of intervention strate-
gies that encourage healthy lifestyles
134. Minio AM, Murphy SL, Xu JQ, Kochanek KD. Deaths: Final data for 2008. National Vital Statistics
Reports; vol 59 no 10. Hyattsville, MD: National Center for Health Statistics.
135. Tangka, FK. Cancer treatment cost in the United States. Cancer. 116.14 (2010):3477.
136. American Cancer Society. Cancer Prevention & Early Detection Facts & Figures 2012. American
Cancer Society. 2012.
137. CDC/National Center for Injury Prevention and Control (NCIPC). WISQARS Years of Potential Life
Lost (YPLL) Report, 2009. Atlanta, GA: US Department of Health and Human Services, CDC, NCIPC.
and preventative care can be effective
in decreasing premature death.
The age-adjusted data vary from
5,621 years lost per 100,000 popula-
tion in Minnesota to 11,113 years lost
per 100,000 population in Mississippi.
The national average is 7,151 years
lost before the age of 75 per 100,000
population, 128 fewer years lost than in
the 2011 Edition. Premature death has
slowly declined since the 2008 Edition,
from 7,490 years lost before age 75 per
100,000 population to the current rate.
Measures
Table 22
Summary Description of Supplemental Measures, 2012 Edition
BEHAVIORS DESCRIPTION SOURCE DATA YEAR(S)
Percentage of adults who have had their blood cholesterol
checked within the last 5 years.
Percentage of adults who have visited the dentist or dental
clinic within the past year for any reason.
Percentage of adults who, during the past month, participated
in any physical activities.
Number of fruits consumed on an average day.
Number of vegetables consumed on an average day.
Number of births per 1,000 mothers age 15 to 19.
Percentage of high school youth who smoked cigarettes on at
least 1 day during the last 30 days.
Percentage of high school students who were greater or
equal to the 95th percentile for body mass index, based on
sex and age-specic reference data from the 2000 CDC
growth charts.
Percentage of adults who have been told by a health
professional that they have angina or coronary heart disease.
Percentage of adults who have had their cholesterol checked
and been told that it was high.
professional that they had a heart attack (myocardial
infarction).
professional that they had a stroke.
professional that they have high blood pressure.
Percentage of babies born before 37 weeks gestation.
Per capita personal income in current dollars.
The amount of income that divides the income distribution
into 2 equal groups.
Total unemployed as a percentage of the civilian labor force
(U-3 denition).
Total unemployed, plus all marginally attached workers, plus
total employed part-time for economic reasons, as a percent
of the civilian labor force plus all marginally attached workers
( ) (U-6 Denition)
A common measure of income inequality, where 0 represents
complete equality and 1 indicates complete inequality.
Percentage of adults who describe their general health
as fair or poor.
Number of deaths due to intentional self-harm
per 100,000 population.
CDC BRFSS
CDC BRFSS
CDC BRFSS
CDC BRFSS
CDC BRFSS
CDC NVSR
CDC YRBS
CDC YRBS
CDC BRFSS
CDC BRFSS
CDC BRFSS
CDC BRFSS
CDC BRFSS
CDC NCHS
U.S. Bureau of Economic Analysis
U.S. Census Bureau, Current
Population Survey, Annual Social
and Economic Supplements
U.S. Bureau of Labor Statistics
U.S. Bureau of Labor Statistics
U.S. Census
CDC BRFSS
CDC NCHS
2011
2010
2011
2011
2011
2010
2011
2011
2011
2011
2011
2011
2011
2010
2011
2011
2011
2011
2011
2011
2009
SUPPLEMENTAL ME TT ASURES
Cholesterol Check
Dental Visit, Annual
Physical Activity
Diet, Fruit
Diet, Vegetables
Teen Birth Rate
Youth Smoking
Youth Obesity
CHRONIC DISEASE
Cardiac Heart Disease
High Cholesterol
Heart Attack
Stroke
Hypertension
CINICAL CARE
CLINICAL CARE
Preterm Birth
ECONOMIC ENVIRONMENT
Personal Income
Median Household Income
Unemployment Rate
Underemployment Rate
Income Disparity (Gini coefcient)
OUTCOMES
Health Status
Suicide
BEHAVIORS
Cholesterol Check measures the
percentage of adults reporting that they
received a cholesterol check within the
past 5 years. These data are collected
by the CDC through the BRFSS. A table
of the percentage of adults receiving a
blood cholesterol check within the last 5
years is at www.americashealthrankings.
org/ALL/CholesterolTest.
The National Cholesterol Education
Program (NCEP) recommends that
adults aged 20 years or older have
their cholesterol checked every 5 years.
High cholesterol has no symptoms,
but a simple blood test can measure
total cholesterol levels, including LDL
(low-density lipoprotein, or bad
cholesterol), HDL (high-density lipo-
protein, or good cholesterol), and
triglycerides. High cholesterol increases
the risk of stroke, heart disease, car-
diovascular disease, and premature
death. Approximately 1 in 6 people are
considered to have high cholesterol.
138
Factors that inuence individuals receiv-
ing a blood cholesterol check include
access, cost, education, and motivation.
Cholesterol can be effectively lowered
with lifestyle modications and medica-
tions. Lowering cholesterol decreases
a persons risk of developing health
conditions such as heart disease, stroke,
and heart attack. The National Heart,
Lung and Blood Institute at the National
Institutes of Health provides additional
background information on cholesterol
and actions you can take to manage
high cholesterol at www.nhlbi.nih.gov/
health/public/heart/index.htm#chol.
In Massachusetts and Rhode Island,
more than 82.0 percent of adults had
their cholesterol checked in the last 5
years. In Utah and Alaska, fewer than
68.0 percent of adults were checked.
The national median of adults who had
their cholesterol checked in the last 5
years is 75.5 percent.
Dental Visit, Annual measures the
percentage of the adult population who
visited a dental clinic for any reason
within the past 12 months. These data
are collected biennially through the
BRFSS by the CDC. A table of the
percentage of adults visiting a dental
ofce within the last year is at www.
americashealthrankings.org/ALL/dental.
Oral health is about more than just a
nice smile; it is a vital part of a com-
prehensive preventive health program.
The Division of Oral Health at the CDC
notes, There are threats to oral health
across the lifespan. Nearly one-third
of all adults in the United States have
untreated tooth decay. One in 7 adults
aged 35 to 44 years has gum disease;
this increases to 1 in every 4 adults
aged 65 years and older. In addition,
nearly a quarter of all adults have expe-
rienced some facial pain in the past 6
months. Oral cancers are most common
in older adults, particularly those over
55 years who smoke and are heavy
drinkers.
139
The mouth can also reveal
information about a patients general
health, as many health conditions such
as tuberculosis have oral manifesta-
tions that could be identied during a
routine oral examination.
140
Factors that
inuence individuals receiving dental
care include access, cost, education,
and motivation. Oral health problems
are preventable through routine visits
to the dentist and good oral hygiene.
Additional information on oral health
can be obtained from CDCs Division of
Oral Health (www.cdc.gov/OralHealth)
and from the American Dental
Association (www.ada.org/365.aspx).
Both websites address questions about
personal oral health and community
programs to improve overall oral health,
such as water uoridation.
In Connecticut and Massachusetts,
more than 81.0 percent of adults had
a dental visit within the last year. In
Mississippi and Oklahoma, fewer than
59.0 percent of adults had a visit in
the last year. The national median of
adults who had a dental visit within
the last year is 70.1 percent.
Physical Activity measures the
percentage of the population who
has participated in any leisure time
physical activity in the last 30 days.
Activities include running, calisthen-
ics, golf, gardening, and walking. This
measure is the inverse proportion of
the sedentary lifestyle core measure.
These data are collected by the
CDC through the BRFSS. A table of
the percentage of adults who have
participated in any physical activi-
ties in the last 30 days is available at
activity.
Regular physical activity is one of
the most important things you can
do for your health as it can improve
current health and reduce the risk
of developing numerous diseases.
Specically, it can help:
Conrrol your weig|r.
Reduce your ris| ol cordiovosculor
disease.
Reduce your ris| lor rype 2
diabetes and metabolic syndrome.
Reduce your ris| ol some concers.
Srrengr|en your 6ones ond
muscles.
mprove your menrol |eolr|
and mood.
mprove your o6iliry ro do doily
activities and prevent falls, if youre
an older adult.
ncreose your c|onces ol living
longer.
141
Not only can physical activity help
with weight loss, but there is also
strong evidence that the benets of
physical activity are independent of
obesity. Even without weight loss,
138. Schober S, Carroll M, Lacher D, Hirsch R. High serum total cholesterol--an indicator for monitoring
cholesterol lowering efforts: U.S. adults, 2005-2006. NCHS Data Brief. 2007(2):1-8.
139. Division of Oral Health, Centers for Disease Control and Prevention (CDC). Adult Oral Health. Updated
2007. http://www.cdc.gov/OralHealth/topics/adult.htm. Accessed August 6, 2012.
140. US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon
General. Rockville, MD: HHS, Ofce of the US Surgeon General; 2000.
141. Centers for Disease Control and Prevention (CDC). State Indicator Report on Physical Activity, 2010
National Action Guide. 2010.
Measures
an obese individual who engages in
physical activity can decrease their
risk of numerous health conditions.
142
Increased physical activity has also been
shown to increase lifespan and quality
of life in patients suffering from a variety
of health conditions.
143
The benets of
increased physical activity continue to
increase with greater levels of activity,
meaning anyone could benet from
additional physical activity.
144
The
2008 Physical Activity Guidelines for
Americans recommends that adults
get at least 30 minutes of moderate
level activity 5 days a week; for even
greater benets the recommendation
doubles to 60 minutes 5 days a week.
145
Community-based interventions have
proven to be successful in increasing
physical activity levels among com-
munity members.
146
A National Action
guide put out by the CDC presents
action items for communities wishing to
increase physical activity.
147
Guidelines
and resources for individuals and com-
munities can be found at www.cdc.gov/
physicalactivity/everyone/guidelines/
index.html.
In Colorado, Utah, California, and
Oregon, more than 80.0 percent of
adults participate in physical activi-
ties. In Mississippi, West Virginia, and
Tennessee, fewer than 65.0 percent
participate. The national median for
physical activity is 73.8 percent of
adults.
Diet, Fruits measures the number
of fruits that adults consume on an
average day. These data are collected
by the CDC through the BRFSS. A
table of the number of fruits consumed
by adults is available at www.
americashealthrankings.org/ALL/fruit.
According to the Dietary Guidelines
for Americans published by the CDC, a
healthy eating plan:
148
Emp|osizes lruirs, vegero6les, w|ole
grains, and fat-free or low-fat milk
and milk products.
ncludes leon meors, poulrry, ls|,
beans, eggs, and nuts.
s low in sorurored lors, rrons lors,
cholesterol, salt (sodium), and added
sugars.
Sroys wir|in your doily colorie needs.
Fruits and vegetables contain essen-
tial vitamins and minerals. They are
also an excellent source of dietary ber.
Consuming 5 or more servings of fruits
and vegetables per day has been shown
to decrease the risk of heart disease
and stroke.
149, 150
Diets high in fruits and
vegetables have also been shown to
help prevent certain types of cancer,
cataracts, and diabetes.
151, 152
Fruits
and vegetables are an integral part of
a healthy diet. Consuming a healthy
diet can not only decrease ones risk of
numerous diseases, but it can also help
to reduce the burden of diseases once
they have been diagnosed by helping
to lower cholesterol, control blood
glucose, and contribute towards weight
loss. Low fruit and vegetable consump-
tion is not only a risk factor itself for
many health conditions; it also increases
the risk of developing other known risk
factors, such as obesity, hypertension,
and hypercholesterolemia.
153
There are many well documented suc-
cessful strategies for increasing fruit and
vegetable intake. However, accessing
healthy foods like fruit and vegetables
can be a challenge depending upon
where you live. The U.S. Department
of Agriculture identies areas of the
country that are food deserts areas
where healthy, wholesome foods are
less readily available (www.ers.usda.
gov/data/fooddesert/fooddesert.html).
Nutritional information is abundant
and overwhelming, but 2 sound starting
points for information are the CDCs
resources about healthy weight (www.
cdc.gov/healthyweight/index.html) and
the National Heart, Lung and Blood
Institute DASH nutrition plan (www.
nhlbi.nih.gov/health/public/heart/hbp/
dash/introduction.html). The DASH
eating plan was originally developed
as an eating plan to reduce high blood
pressure, i.e. hypertension. (DASH
stands for Dietary Approaches to Stop
Hypertension.) However, the plan also
represents a healthy approach to eating
for those who do not have a problem
with hypertension.
Fruits servings vary from a high of
1.23 servings per adult per day in
California to a low of 0.71 servings
per adult per day in Mississippi and
Louisiana. Nationally, the median con-
sumption is 0.99 servings per day for
each adult.
Diet, Vegetables measures the
number of vegetables that adults
consume on an average day. These
data are collected by the CDC
through the BRFSS. A table of the
number of vegetables consumed
by adults is available at www.
americashealthrankings.org/ALL/veggie.
Vegetable servings vary from a high
of 0.90 servings per adult per day in
Maine, New Hampshire, and Vermont
to a low of 0.65 servings per adult per
day in Louisiana. Nationally, the median
consumption is 0.79 servings per day
for each adult.
Teen Birth Rate measures the number
of births per 1,000 mothers ages 15
142. Jakicic JM. Physical activity considerations for the treatment and prevention of obesity. Am J Clin Nutr.
2005;82(1):226S.
143. Warburton DER. Health benets of physical activity: The evidence. CMAJ. 2006;174(6):801.
144. Bouchard C. Physical activity and health: Introduction to the dose-response symposium. Med Sci Sports
Exerc. 2001;33(6):S347.
145. US Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans. 2008.
146. Kahn EB. The effectiveness of interventions to increase physical activity: A systematic review 1 and 2. Am
J Prev Med. 2002;22(4):73.
147. Centers for Disease Control and Prevention (CDC). State Indicator Report on Physical Activity, 2010
National Action Guide. Atlanta, GA: US Department of Health and Human Services; 2010.
148. Centers for Disease Control and Prevention (CDC), http://www.cdc.gov/healthyweight/healthy_eating/
index.html. Accessed October 26, 2011.
149. He FJ. Fruit and vegetable consumption and stroke: Meta-analysis of cohort studies. Lancet.
2006;367(9507):320.
150. He FJ. Increased consumption of fruit and vegetables is related to a reduced risk of coronary heart
disease: Meta-analysis of cohort studies. J Hum Hypertens. 2007;21(9):717
151. Van Duyn M. Overview of the health benets of fruit and vegetable consumption for the dietetics
professional: Selected literature. J Am Diet Assoc. 2000;100(12):1511.
152. Ford ES. Fruit and vegetable consumption and diabetes mellitus incidence among US adults. Prev Med.
2001;32(1):33.
153. Rolls BJ, Ello-Martin JA, Tohill BC. What can intervention studies tell us about the relationship between
fruit and vegetable consumption and weight management? Nutr Rev. 2004;62(1):1-17.
to 19. These data are collected by the
CDC from birth certicates as part of
the National Vital Statistics System.
The birth rate for teens can be found at
www.americashealthrankings.org/ALL//
teenbirth.
Prevention of teen and unplanned
pregnancy is an important part of a
healthy community. According to the
CDC, 409,840 infants were born to 15
to 19 year olds in 2009, for a live birth
rate of 39.1 births per 1,000 women
in this age group. Nearly two-thirds of
these births were unintended in girls
younger than age 18 and more than
half were unintended among 18 to
19 year olds.
154
CDC estimates that
teen pregnancy costs more than $9
billion per year to U.S. taxpayers for
increased health care and foster care,
increased incarceration rates among
children of teen parents, and lost tax
revenue because of lower educational
attainment and income among teen
mothers.
155
A valuable resource for
further information about teen and
unplanned pregnancy is available from
The National Campaign to Prevent Teen
and Unplanned Pregnancy (www.the-
nationalcampaign.org/default.aspx).
Teen birth rates are lowest in New
Hampshire at 15.7 births per 1,000
mothers ages 15 to 19 and highest in
Mississippi with 55.0 births per 1,000
mothers ages 15 to 19. The national
rate is 34.2 births per 1,000 mothers
ages 15 to 19.
Youth Smoking measures the percent-
age of high school youth that smoked
cigarettes on at least 1 day during the
last 30 days. These data are collected
by the CDC through the High School
Youth Risk Behavior Survey. The survey
was only administered in 41 states,
so data is not available for all states.
A table of the percentage of youth
who smoke cigarettes is available at
youthsmoking.
Smoking is most commonly associ-
ated with negative health effects in
adulthood, but there are immedi-
ate effects even in young smokers.
Adolescents who smoke are less
physically t and have more respiratory
illness than their nonsmoking peers.
156
Tobacco use during adolescence is
associated with other behaviors such as
high risk sexual activities, alcohol use,
and illicit drug use.
157
Youth smoking is
predictive of adult smoking as smoking
often begins in adolescence or young
adulthood; nearly 60 percent of current
smokers report having started before
age 18.
158
One of the goals of Healthy
People 2020 is to reduce the proportion
of adolescents who smoke cigarettes in
the past 30 days to 16 percent.
Smokers who quit before age 35
reduce their risk of premature death
to almost the same level as non-smok-
ers.
159
A wide variety of intervention
types have been found to be effective
in leading to smoking cessation at the
individual and community levels.
160
Many policy efforts have been tried
over the past several decades including
excise taxes and smoking bans. Both
of these policy approaches have been
shown to be tremendously effective in
leading to cessation, preventing non-
smokers from starting and decreasing
smoking-related health problems.
161,162
Due to the widespread negative health
effects of secondhand smoke, reducing
the prevalence of smoking and creating
smoke-free environments can have a
profound impact on the entire com-
munity.
163
For more information and
resources to help you quit, see www.
smokefree.gov/.
Smoking is a lifestyle behavior that
an individual can directly inuence
with support from the community
and, as required, clinical intervention.
Cessation, even in a longtime smoker,
can have profound benets on current
health status as well as on long term
outcomes.
164
Youth smoking varies from a low of
5.9 percent of high school youth in Utah
to a high of 24.1 percent in Kentucky.
Nationwide, 18.1 percent of youth had
smoked cigarettes on at least 1 day
during the 30 days before the survey.
Youth Obesity measures the
percentage of high school youth who
were greater than or equal to the 95th
percentile for BMI, based on sex and
age-specic reference data from the
2000 CDC Growth Charts. These data
are collected by the CDC through the
High School Youth Risk Behavior Survey.
The survey was only administered in
41 states, so data is not available for
all states. A table of the percentage
of obese youth is available at www.
americashealthrankings.org/all/
youthobesity.
Obesity is one of the greatest health
threats to the U.S. It contributes signi-
cantly to a variety of serious diseases,
including heart disease, diabetes,
stroke, and certain cancers as well as
poor general health.
165
Obesity has
many well documented long-term
negative health effects, many of which
154. Centers for Disease Control and Prevention (CDC). Vital signs: Teen pregnancyUnited States, 1991
2009. MMWR 2011;60(13):414-420.
155. Centers for Disease Control and Prevention (CDC), http://www.cdc.gov/TeenPregnancy/AboutTeenPreg.
htm. Accessed October 26, 2011.
156. Milton MH, Maule CO, Yee SL, Backinger C, Malarcher AM, Husten CG. Youth Tobacco Cessation: A
Guide for Making Informed Decisions. Atlanta, GA: US Department of Health and Human Services,
Centers for Disease Control and Prevention; 2004.
157. US Department of Health and Human Services. Preventing Tobacco Use Among Youth and Young Adults.
Centers for Disease Control and Prevention, Ofce on Smoking and Health; 2012.
158. Substance Abuse & Mental Health Services Administration. Results from the 2010 National Survey on
Drug Use and Health: National Findings. Department of Health and Human Services; 2011.
159. Taylor Jr. DH, Hasselblad V, Henley SJ, Thun MJ, Sloan FA. Benets of smoking cessation for longevity.
Am J Public Health. 2002;92(6):990-996. http://articles.sirc.ca/search.cfm?id=S-833157;
160. Lemmens V, Oenema A, Knut IK, Brug J. Effectiveness of smoking cessation interventions among adults:
A systematic review of reviews. European Journal of Cancer Prevention. 2008;17(6):535.
161. Chaloupka FJ. Effectiveness of tax and price policies in tobacco control. Tob Control. 2011;20(3):235.
162. Naiman A. Association of anti-smoking legislation with rates of hospital admission for cardiovascular and
respiratory conditions. CMAJ. 2010;182(8):761.
163. US Department of Health and Human Services. The Health Consequences of Involuntary Exposure to
Tobacco Smoke: A Report of the Surgeon General. Atlanta, GA: Centers for Disease Control and Preven-
tion, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and
Health Promotion, Ofce on Smoking and Health; 2006.
164. US Department of Health and Human Services. The Health Consequences of Smoking: A Report of the
Surgeon General. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Chronic
Disease Prevention and Health Promotion, Ofce on Smoking and Health; 2004.
165. Centers for Disease Control and Prevention (CDC). Overweight and Obesity. May 24, 2012. http://www.
cdc.gov/obesity/. Accessed July 24, 2012.
Measures
can start in adolescence as 70 percent
of obese adolescents already have at
least 1 risk factor for cardiovascular
disease.
166,167
Children and adolescents
who are obese are at increased risk of
developing immediate health problems
such as bone or joint problems, sleep
apnea, and social or psychological
problems.
168
The causes of obesity are
complex and include lifestyle, the social
and physical environment, as well as
genes and medical history. Poor diet
and decreased physical activity are
major lifestyle contributors to obesity.
Since the 1980s, energy intake has
steadily climbed and energy expendi-
ture has declined, leading to a growing
energy imbalance which closely mirrors
the obesity rates.
169
There have been
successful interventions targeting a
wide variety of populations with dif-
ferent strategies, from school based
prevention programs to behavioral
interventions.
170, 171
While obesity is
associated with an increased risk of
developing numerous health condi-
tions, weight loss is associated with an
attenuation of those risks. For more
information, additional resources, and
strategies to prevent and reduce child-
hood obesity, visit www.letsmove.gov.
Youth obesity varies from a low of
7.3 percent of high school youth in
Colorado to a high of 17.0 percent in
Alabama. Nationwide, 13.0 percent
of high school youth are obese. A fact
sheet is available at www.cdc.gov/
healthyyouth/yrbs/pdf/us_obesity_
trend_yrbs.pdf.
Chronic Disease is comprised of 5
measures that capture the risk factors
and burden of cardiovascular diseases:
cardiac heart disease, high cholesterol,
heart attack, stroke, and hypertension.
These measures represent the burden of
cardiovascular diseases and risk factors
on the population. Cardiovascular
disease (heart disease and stroke) is the
leading cause of death in the U.S. and
is a signicant contributor to morbid-
ity. All 5 chronic disease measures are
self-reported by respondents to the
BRFSS. Resources for heart and vascular
diseases are at National Heart, Lung
and Blood Institute (www.nhlbi.nih.gov/
health/public/heart/index.htm) as well
as at the Division for Heart Disease and
Stroke Prevention, CDC (www.cdc.gov/
DHDSP/index.htm).
Cardiac Heart Disease measures
the percentage of the population over
age 18 who were told by a health
professional that they have angina
or coronary heart disease. Heart
disease alone has consistently been
the leading cause of death in the
U.S. The estimated economic cost of
heart disease exceeds $100 billion
annually.
172
A table of the percentage of
adults with heart disease is available at
CHD.
The prevalence of heart disease
ranges from less than 3.0 percent of
adults in Colorado and Alaska to a high
of 6.7 percent in West Virginia. The
national median is 4.1 percent of adults.
High Cholesterol measures the
percentage of the population over age
18 who had their cholesterol checked
and told that it was high. High choles-
terol is usually dened as total blood
cholesterol above 240 mg/dL. High
cholesterol, a major risk factor for heart
disease, can be inuenced by lifestyle
behaviors such as diet and physical
activity but is also inuenced by
heredity. A table of the percentage of
adults with high cholesterol is available
high_chol.
The prevalence of high cholesterol
ranges from less than 35.0 percent of
adults in Colorado, Massachusetts,
Alaska, Montana, and Utah to 42.0
percent or more in Alabama and
Mississippi. The national median is
38.4 percent of adults.
Heart Attack measures the percent-
age of the population over age 18 who
have been told by a health professional
that they had a heart attack. A heart
attack, or myocardial infarction, is a
sudden stoppage of blood ow to the
tissue of the heart. Every year there are
an estimated 1 million heart attacks
and half a million deaths as a result in
the U.S.
173
A table of the percentage of
adults who have had heart attacks is at
www.americashealthrankings.org/all/MI.
The prevalence of heart attacks
ranges from 2.7 percent of adults in
Colorado to more than 6.0 percent in
Kentucky, West Virginia, and Arkansas.
The national median is 4.4 percent
of adults.
Stroke measures the percentage of
the population over age 18 who have
been told by a health professional
that they had a stroke. A stroke occurs
when a blood clot in the brain blocks
circulation to parts of the brain or
causes the vessel to burst. Stroke
is a leading cause of death in the
U.S., and every year there are almost
800,000 strokes.
174
The estimated
economic cost of stroke is $54 billion
annually.
175
Strokes often lead to
serious disability, and stroke is a
leading cause of long-term disability.
A table of the percentage of adults
who have had a stroke is at www.
americashealthrankings.org/all/stroke.
The prevalence of stroke ranges
from a low of 2.0 percent of adults in
Colorado to 4.0 percent or more in
Arkansas, Mississippi and Alabama. The
national median is 2.9 percent of adults.
Hypertension, or High Blood
Pressure, measures the percentage of
166. Malnick SDH. The medical complications of obesity. QJM. 2006;99(9):565.
167. Freedman DS. Cardiovascular risk factors and excess adiposity among overweight children and adoles-
cents: The Bogalusa heart study. J Pediatr. 2007;150(1):12.
168. Dietz WH. Overweight in childhood and adolescence. N Engl J Med. 2004;350(9):855.
169. Finkelstein EA. Economic causes and consequences of obesity. Annu Rev Public Health. 2005;26(1):239.
170. Shaya FT. School based obesity interventions: A literature review. J Sch Health. 2008;78(4):189.
171. Kamath CC. Behavioral interventions to prevent childhood obesity: A systematic review and metaanaly-
ses of randomized trials. J Clin Endocrinol Metab. 2008;93(12):4606.
172. Heidenreich PA, Trogdon JG, Khavjou OA, et al. Forecasting the future of cardiovascular disease in the
United States: A policy statement from the American Heart Association. Circulation. 2011;123(8):933-944.
173. Lloyd Jones, D. Heart disease and stroke statistics2010 update. Circulation. 121.7 (2010):e46.
174. Minio AM, Murphy SL, Xu J, Kochanek KD. Deaths: Final data for 2008. National Vital Statistics Reports;
vol 59 no 10. Hyattsville, MD: National Center for Health Statistics; 2011.
175. Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics-2011 update: A report from
the American Heart Association. Circulation. 2011;123(4):e18
the population over age 18 who have
been told by a health professional
that they have high blood pressure.
High blood pressure is a major modi-
able risk factor for heart disease and
stroke. Hypertension often has no
symptoms and is estimated to afict 1 in
3 Americans.
176
Hypertension and high
cholesterol are modiable risk factors
that can be addressed through various
interventions, including behavior and
pharmaceutical.
177
Individuals should
be regularly screened for both condi-
tions and maintain a healthy lifestyle to
prevent both risk factors. A table of the
percentage of adults with hypertension
is at www.americashealthrankings.org/
all/hypertension.
The prevalence of high blood
pressure ranges from a low of 22.9
percent of adults in Utah to a high of
40.1 percent in Alabama. The national
median is 30.8 percent of adults.
CLINICAL CARE
Preterm Birth measures the percentage
of births delivered preterm, prior
to 37 weeks. Full term is dened
as 40 weeks gestation. These data
are collected by the CDC from birth
certicates as part of the National Vital
Statistics System. The percentage of
preterm births can be found at www.
americashealthrankings.org/ALL/
preterm.
Every year there are 500,000 preterm
births, roughly 1 of every 8 births. While
babies born late-preterm (between
34 and 36 weeks) are usually healthier
than babies born earlier; they are 3
times more likely to die in the rst year
of life than full-term infants.
178
They
are also at increased risk of newborn
health problems, including breathing
and feeding problems. Preterm births
are more likely to be low birthweight
than full-term births. Some late-preterm
births result from early induction of
labor or cesarean delivery due to preg-
nancy complications. However, in some
cases, early delivery may occur without
good medical justication. Preterm
births are estimated to cost $5.9 billion
in direct medical costs.
179
In Vermont and New Hampshire,
fewer than 9.5 percent of babies are
born preterm. In Mississippi, Louisiana
and Alabama, more than 15.0 percent
of babies are born preterm. The
national rate of babies born preterm is
12.0 percent.
Economic environment measures the
environment in which health is being
assessed though several key indicators
of economic status. Health is inuenced
by many factors, one of them being
the economic means of the population.
Health status is associated with wealth
as those with more wealth have greater
means to access health care and healthy
lifestyles. Five measures are used to
gauge the economic environment of
a state: median household income,
personal income, unemployment rate,
underemployment rate, and income
disparity.
Income is an individuals
income and reects the ability of
that individual to afford aspects of a
healthy lifestyle, preventive medicine,
and curative care not provided to
the individual through government,
business, trade groups, or other
sources. Per capita personal income
is total personal income divided by
total mid-year population. Data for
personal income is from the Regional
Economic Information System, Bureau
of Economic Analysis, U.S. Department
of Commerce and is available at www.
americashealthrankings.org/all/income.
Personal income has also been shown
to be negatively correlated to morbid-
ity and mortality, meaning that higher
income individuals experience lower
illness and death.
180
This relationship
is independent of poverty, meaning
a person with low personal income
is more likely to have poorer health
regardless of whether or not they are
classied as living in poverty.
Personal income ranges from a high
of almost $57,000 in Connecticut to
a low of $32,000 in Mississippi. The
national median is approximately
$42,000.
Median Household Income is the
amount of income that divides the
income distribution into 2 equal groups:
half with income above that amount
and half with income below that
amount. Data for household income is
from the U.S. Census Bureau, Current
Population Survey, Annual Social and
Economic Supplements and is available
MedianIncome.
The median household income
combines the incomes of all members
of a household and is an indicator of
the relative wealth of an area the
higher the median household income,
the more wealthy the area. Household
income reects the ability for that
household to afford aspects of a healthy
lifestyle, including preventive medicine
and curative care not provided to
the individual through government,
business, trade groups, or other
sources.
Median household income ranges
from a high of almost $69,000 in
Maryland to a low of almost $40,000 in
Kentucky. Nationally, the median annual
household income is $50,000.
Unemployment Rate measures the
total percentage of the civilian labor
force that is unemployed. For most,
employment is the source of income
for sustaining a healthy life and for
accessing health care. For many indi-
viduals, their employer is the source
for their health care insurance. The
U.S. Department of Labors Bureau of
176. Centers for Disease Control and Prevention (CDC). Vital signs: prevalence, treatment, and control of
hypertensionUnited States, 1999-2002 and 2005-2008. MMWR. 2011;60(4):103-8.
177. Chobanian, AV. Seventh report of the joint national committee on prevention, detection, evaluation, and
treatment of high blood pressure. Hypertension. 42.6 (2003):1206.
178. Macdorman MF, Mathews TJ. Recent trends in infant mortality in the United States. NCHS Data Brief.
2008;(9):1-8.
179. St John EB, Nelson KG, Cliver SP, Bishnoi RR, Goldenberg RL. Cost of neonatal care according to
gestational age at birth and survival status. Obstet Gynecol. 2000;182(1):170-5.
180. Friscella K, Franks P. Poverty or income inequality as predictor of mortality: Longitudinal cohort study.
BMJ. 1997;314(7096):1724.
Measures
Labor Statistics releases unemploy-
ment gures monthly and annually.
The ofcial denition of the unemploy-
ment rate is total unemployed, as a
percent of the civilian labor force and
is the gure most widely published
by the media. This data is available at
unemployed.
Employer-sponsored health insur-
ance is the most common form of
health insurance in the U.S., and the
unemployment rate provides informa-
tion about the number of uninsured.
Unemployment is also a contributor
towards poverty, another cause of
ill health. Unemployment has been
associated with an increase in unhealthy
behaviors such as poor diet, lack of
exercise, tobacco use, and excessive
alcohol consumption.
181
Unemployment rate ranges from a
low of 3.6 percent in North Dakota,
to a high of 13.1 percent in Nevada.
The national unemployment rate is 8.9
percent.
Underemployment Rate measures
the percentage of the civilian labor
force that are unemployed, all
marginally attached workers, plus those
employed part-time for economic
reasons. Many suggest that the ofcial
unemployment rate does not reect
the full impact of employment on the
market. The Bureau of Labor Statistics
uses an expanded denition to allow
for individuals who are no longer
seeking employment, those employed
only part-time when they desire full-
time work, and workers who are only
marginally attached, that is persons
who currently are neither working nor
looking for work but indicate that they
want and are available for a job and
have looked for work sometime in the
recent past. This data is available at
underemployed.
The connection between under-
employment and health has been
studied far less than that between
unemployment and health; however,
the existing evidence suggests under-
employment is also associated with
ill health.
182
Underemployment leads
to decreased earning which limits
ones access to health care. Persons
who are underemployed are more
likely than other individuals to report
lower levels of general well-being.
183
Underemployment is also associated
with a lack of health insurance.
The underemployment rate ranges
from a low of 6.6 percent in North
Dakota to a high of 22.7 percent in
Nevada. The national underemploy-
ment rate is 15.9 percent.
Income Disparity, or the Gini
coefcient, is a common measure of
income inequality. It varies between
0, which reects complete equality
of income, and 1, which indicates
complete inequality (one person
has all the income or consumption,
all others have none). Historically,
the U.S. index has varied from
0.386 in 1968 to 0.469 in 2010
(www.census.gov/prod/2011pubs/
acsbr10-02.pdf). The source for
the data is U.S. Census Bureau,
Current Population Survey, 1978 to
2010 Annual Social and Economic
Supplements and is available at www.
americashealthrankings.org/all/gini.
Socioeconomic status, personal
income, and poverty are clear determi-
nants of health; income disparity has
been associated with poorer health,
but its effect alone is difcult to disen-
tangle.
184
There are many hypotheses
regarding income disparity and health,
but none of them has overwhelming
support. Income disparity has been
clearly associated with self-reported
health. Low-income people living in
areas with greater income disparity
report poorer health than those living in
areas with less disparity.
185
Self per-
ceived health refers to overall wellness
and is an important health indicator
by itself. Income disparity reects the
community and will play a role in how
a community will develop plans and
take actions to change health. As such,
income disparity provides a valuable
description of the environment in which
health improvement programs must
be implemented. Eliminating income
inequity may not be a valid nor practical
means to improve health, but recog-
nizing that it does have an impact is
important in designing interventions to
target other measures of health.
Most developed European nations
and Canada have Gini indices between
0.24 and 0.36 (the Gini Index, which
is the Gini coefcient times 100, is
reported for other countries by the
Central Intelligence Agency at https://
www.cia.gov/library/publications/the-
world-factbook/elds/2172.html).
Income disparity ranges from a low
of 0.41 in Alaska and Wyoming to a
high of 0.50 in New York. The national
average is 0.48.
OUTCOMES
Health Status measures the percentage
of adults who rate their general health
as fair or poor. The 2012 data comes
from the 2011 BRFSS data and are at
HealthStatus. The BRFSS telephone
by people using landlines. During
the elding of the 2011 BRFSS, the
methodology was updated to include
cellular telephones due to the large
number of households that contain only
cellular telephones and no landline
telephones. Because of these changes,
estimates of health status from the 2012
to estimates from previous years.
181. Dooley D, Fielding J, Levi L. Health and unemployment. Annu Rev Public Health. 1996;17:449-65.
182. Friedland DS. Underemployment: Consequences for the health and well-being of workers.
Am J Community Psychol. 2003;32(1/2):33.
183. Wooden M. Working time mismatch and subjective well being. Br J Ind Relat. 2009;47(1):147.
184. Wagstaff A. Income inequality and health: What does the literature tell us? Annu Rev Public Health.
2000;21(1):543.
185. Kennedy BP, Kawachi I, Glass R, Prothrow-Stith D. Income distribution, socioeconomic status, and self
rated health in the United States: Multilevel analysis. BMJ. 1998;317(7163):917.
Shifts in estimates from previous years
may be the result of the new methods
percentages.
Self-reported health status is an
indicator of the populations self-per-
ceived health. It is a more subjective
measure of health that is not limited to
certain health conditions or outcomes.
It is instead inuenced by life experi-
ence, the health of others in ones
life, and many other factors affecting
ones overall well-being.
186
Research
has shown that those with a poorer
self-reported health status have higher
rates of mortality from all causes.
187
The
association between health status and
mortality make it a good predictor of
not only future mortality rates, but also
future health care use as persons with
poor health status will seek care.
188
Health status ranges from a low of
12.0 percent in Minnesota to a high
of 25.1 percent in West Virginia. The
national median is 16.9 percent.
Suicide measures the number of
deaths due to intentional injuries
per 100,000 population. The data is
provided by the National Vital Statistics
System and is available at www.
americashealthrankings.org/all/suicide.
Suicide is a major cause of death
in the U.S. In 2010 there were nearly
38,000 suicides, making it the tenth
leading cause of death.
189
Furthermore,
there are twice as many deaths from
suicide each year than from homicides.
For each successful suicide there are
roughly 10 attempted suicides, many
of which lead to hospitalizations, and
are an indicator of the burden of poor
mental health in the population.
190
Suicide is of great concern in younger
people, as it is the third leading cause
of death in 15 to 24 year olds and the
fourth leading cause of death in 25 to
44 year olds, making it a signicant con-
tributor to premature death.
191
Suicide
not only affects the individual but can
also have serious effects on the family
and friends. The burden of suicide
can be lessened though prevention
strategies. For resources and effective
prevention strategies, see www.sprc.
org/.
The suicide rate ranges from 6.3
deaths per 100,000 population in New
Jersey to a high of 21.8 deaths per
100,000 population in Montana. The
national rate is 12.0 deaths per 100,000
population.
186. Idler E. In sickness but not in health: Self-ratings, identity, and mortality. J Health Soc Behav.
2004;45(3):336.
187. DeSalvo KB. Mortality prediction with a single general self rated health question. Journal of General
Internal Medicine. 2006;21(3):267.
188. DeSalvo KB. Predicting mortality and healthcare utilization with a single question. Health Serv Res.
2005;40(4):1234
189. Murphy SL, Xu J, Kochanek KD. Deaths: Preliminary data for 2010. National Vital Statistics Report, 2012;4.
190. Miller M. Suicide prevention. Annu Rev Public Health. 2012;33(1):393.
191. Murphy SL, Xu J, Kochanek KD. Deaths: Preliminary data for 2010. National Vital Statistics Report, 2012;4.
Index
Index of Tables, Figures, and Graphs
DESCRIPTION PAGE NUMBER
TABLES
1 Overall Rankings, 2012 Edition 14
2 Determinants and Outcomes, 2012 Edition 15
3 National Successes and Challenges, 2012 Edition 17
4 Prevalence of Smoking by Race/Ethnicity and State, 2012 Edition 21
5 Prevalence of Sedentary Lifestyle by Race/Ethnicity and State, 2012 Edition 22
6 Prevalence of Obesity by Race/Ethnicity and State, 2012 Edition 23
7 Infant Mortality Rate by Race, 2012 Edition 24
8 International Comparisons 26
9 Weight of Individual Measures, 2012 Edition 29
10 Determinants and Outcomes, 2012 Edition 31
11 2012 Determinants-Highest and Lowest Ranked States 31
12 2012 Outcomes-Highest and Lowest Ranked States 31
13 Summary Description of Measures, 2012 Edition 32
14 Top Improvements in High School Graduation 36
15 Greatest Decreases in Children in Poverty 38
16 Greatest Increases in Children in Poverty 38
17 Greatest Decreases in Lack of Health Insurance 40
18 Greatest Decreases in Infant Mortality 45
19 Greatest Decreases in Cardiovascular Deaths 46
20 Greatest Decreases in Cancer Deaths 46
21 Greatest Decreases in Premature Death 47
22 Summary Description of Supplemental Measures, 2012 Edition 48
FIGURES
1 Components of Health 9
GRAPHS
1 Preventable Hospitalizations Since 2001 18
2 Cardiovascular Deaths Since 2001 18
3 Life Expectancy at Birth 18
4 Children in Poverty Since 2001 19
5 Infant Mortality Since 1990 19
6 Low Birthweight Infants Since 1993 19
State-By-State Snapshots
The following pages describe the overall ranking, strengths, challenges, and signicant
changes for each state. To compare your state to other states or to other years, go to TT
www.americashealthrankings.org/all and select the display options that you desire.
On each states snapshot, there is a separate paragraph that describes aspects of
the health disparities within that state and includes the number of adults affected by
smoking, obesity, sedentary lifestyle, and diabetes. For disparity information for all states,
see page 20 or go to www.americashealthrankings.org/Rankings and click on the Health
Disparities tab.
Each snapshot also contains the current economic climate of the state. Tabular data for TT
this information is available by going to www.americashealthrankings.org/all and select-
ing the desired measure from the drop down list.
In addition, supplemental measures of health and economic status are available for
each state at www.americashealthrankings.org/all.
UNI TED HEALTH FOUNDATI ON | AMERI CA S HEALTH RANKI NGS
2 012
59
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
MEASURE ADULT POPULATION
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
Smoking (Percent of adult population)
Binge Drinking (Percent of adult population)
Obesity (Percent of adult population)
Sedentary Lifestyle (Percent of adult population)
High School Graduation (Percent of incoming ninth graders)
Violent Crime (Offenses per 100,000 population)
Occupational Fatalities (Deaths per 100,000 workers)
Infectious Disease (Cases per 100,000 population)
Children in Poverty (Percent of persons under age 18)
Air Pollution (Micrograms of ne particles per cubic meter)
Lack of Health Insurance (Percent without health insurance)
Public Health Funding (Dollars per person)
Immunization Coverage (Percent of children ages 19 to 35 months)
Low Birthweight (Percent of live births)
Primary Care Physicians (Number per 100,000 population)
Preventable Hospitalizations (Number per 1,000 Medicare enrollees)
Diabetes (Percent of adult population)
Poor Mental Health Days (Days in previous 30 days)
Poor Physical Health Days (Days in previous 30 days)
Geographic Disparity (Relative standard deviation)
Infant Mortality (Deaths per 1,000 live births)
Cardiovascular Deaths (Deaths per 100,000 population)
Cancer Deaths (Deaths per 100,000 population)
Premature Death (Years lost per 100,000 population)
STATE NATION
The 2012 data in the above
graphs are not directly
comparable to prior years.
See Methodology for
additional information.
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
Annual Unemployment Rate (2011)
Annual Underemployment Rate (2011)
Median Household Income (2011)
24.3
13.7
32.0
32.6
69.9
378
4.7
12.9
21.6
11.0
14.3
$116
92.2
10.3
97.9
80.1
-0.26
11.8
4.8
4.6
8.1
8.9
333.0
203.8
10,496
-0.26
-0.52
41
4
47
46
43
30
28
40
28
41
27
10
14
48
40
44
41
46
48
45
8
48
49
44
48
47
45
893,000
1,176,000
434,000
1,198,000
Ranking: Alabama is 45th this year; it was 48th in 2011.
Highlights:
Almosr 1.2 million aculrs in AlaLama are oLese, anc 1.2
million aculrs leac a secenrary lilesryle.
There are 434,000 aculrs wirh ciaLeres in rhe srare.
Smokin remains hih ar 24.3 percenr ol rhe aculr popularion,
wirh almosr 00,000 aculr smokers in AlaLama.
Hih school racuarion rares have improvec in rhe lasr 5 years
lrom c5.0 percenr ro c. percenr ol incomin ninrh racers
who racuare wirhin 4 years.
n rhe pasr 5 years, rhe rare ol prevenraLle hospiralizarions
cecreasec lrom 4.8 ro 80.1 cischares per 1,000 Mecicare
enrollees.
n rhe lasr year, rhe inlanr morraliry rare ceclinec lrom .7 ro
8. cearhs per 1,000 live Lirrhs.
Health Disparities:
n AlaLama, oLesiry is more prevalenr amon nonHispanic
Llacks ar 43.1 percenr rhan Hispanics ar 31.1 percenr anc non
Hispanic whires ar 28.8 percenr, anc smokin is more prevalenr
amon Hispanics ar 31. percenr rhan nonHispanic whires ar
22.0 percenr anc nonHispanic Llacks ar 21.7 percenr.
State Health Department Website: www.acph.or
ALABAMA
A
L
A
B
A
M
A
For o more deroiled loo| or r|is doro, visir
www.americashealthrankings.org/AL
AL U.S.
9.8% 8.9%
16.2% 15.9%
$42,590 $50,054
2 012
60
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
22.9
20.8
27.4
22.0
72.6
639
8.1
8.2
14.8
6.0
18.2
$200
88.7
5.7
111.9
54.5
0.13
7.9
3.2
3.8
28.7
6.3
219.3
186.2
7,761
-0.05
0.08
34
41
23
9
40
49
47
16
12
3
39
2
35
1
27
11
23
5
7
19
49
24
6
31
29
34
28
AK U.S.
7.6% 8.9%
13.5% 15.9%
$57,431 $50,054
122,000
146,000
42,000
118,000
Ranking: Alaska is 28th this year; it was 29th in 2011.
Highlights:
Almosr 150,000 aculrs in Alaska are oLese, anc more rhan
40,000 aculrs in rhe srare have ciaLeres.
More rhan 120,000 aculrs smoke in Alaska.
Hih school racuarion rares improvec in rhe lasr lve years
lrom c7.2 percenr ro 72.c percenr ol incomin ninrh racers
who racuare wirhin 4 years.
enrollees.
The numLer ol occuparional laraliries cecreasec lrom 12.5 ro
8.1 cearhs per 100,000 workers in rhe pasr 5 years.
n rhe pasr 10 years, rhe rare ol carciovascular cearhs cecreasec
lrom 284.7 ro 21.3 cearhs per 100,000 popularion.
Health Disparities:
n Alaska, oLesiry is more prevalenr amon nonHispanic Narive
Americans ar 30.8 percenr rhan nonHispanic whires ar 23.7
percenr, anc smokin is more prevalenr amon nonHispanic
Narive Americans ar 37. percenr rhan nonHispanic whires ar
17.5 percenr anc Hispanics ar 2c.1 percenr.
State Health Department Website: hrrp://healrh.hss.srare.ak.us

ALASKA
A
L
A
S
K
A
www.americashealthrankings.org/AK
2 012
61
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
19.2
18.0
24.7
24.2
72.5
408
3.5
10.8
24.7
9.4
18.2
$45
88.4
7.1
95.7
52.9
0.06
9.6
4.0
3.7
16.7
6.2
210.3
157.6
7,107
0.08
0.14
14
23
11
16
41
33
12
32
43
25
39
45
36
15
42
10
28
26
31
16
41
22
2
3
21
21
25
933,000
1,200,000
466,000
1,175,000
Ranking: Arizona is 25th this year; it was 27th in 2011.
Highlights:
Almosr 1.2 million aculrs in Arizona leac a secenrary lilesryle,
anc 1.2 million are oLese.
Almosr hall a million aculrs in Arizona have ciaLeres.
cecreasec lrom c1.5 ro 52. cischares per 1,000 Mecicare
enrollees.
n rhe lasr year, rhe percenrae ol chilcren in poverry cecreasec
lrom 27.3 percenr ol persons uncer ae 18 ro 24.7 percenr.
n rhe pasr year, rhe rare ol carciovascular cearhs cecreasec
n rhe pasr 5 years, rhe rare ol cancer cearhs ceclinec lrom 175.4
ro 157.c cearhs per 100,000 popularion.
Health Disparities:
n Arizona, oLesiry is more prevalenr amon Hispanics ar 31.0
percenr rhan nonHispanic whires ar 24.1 percenr.
State Health Department Website: www.azchs.ov
ARIZONA
A
R
I
Z
O
N
A
www.americashealthrankings.org/AZ
AZ U.S.
9.5% 8.9%
18.0% 15.9%
$48,621 $50,054
2 012
62
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
27.0
14.1
30.9
30.9
74.0
505
7.9
19.3
25.4
10.8
18.0
$91
91.0
8.8
98.0
79.3
-0.48
11.2
5.2
4.9
11.1
7.5
316.5
206.4
10,098
-0.24
-0.72
48
5
44
44
36
41
46
49
46
39
37
18
22
39
39
43
48
44
50
48
22
38
45
46
45
46
48
AR U.S.
8.6% 8.9%
14.1% 15.9%
$41,302 $50,054
601,000
688,000
249,000
688,000
Ranking: Arkansas is 48th this year; it was 47th in 2011.
Highlights:
Almosr 700,000 aculrs in Arkansas are oLese, anc rhe same
numLer ol aculrs leac a secenrary lilesryle.
Smokin remains hih ar 27.0 percenr ol rhe aculr popularion, wirh
more rhan c00,000 aculr smokers in rhe srare.
There are almosr a quarrermillion aculrs wirh ciaLeres in Arkansas.
n rhe pasr year, rhe percenrae ol chilcren in poverry increasec
lrom 21.8 percenr ro 25.4 percenr ol persons uncer rhe ae ol 18.
n rhe pasr year, rhe rare ol prevenraLle hospiralizarions cecreasec
lrom 81.5 ro 7.3 cischares per 1,000 Mecicare enrollees.
n rhe pasr 10 years, rhe inlanr morraliry rare cecreasec lrom 8.2 ro
7.5 cearhs per 1,000 live Lirrhs.
lrom 354.2 ro 31c.5 cearhs per 100,000 popularion.
Health Disparities:
n Arkansas, oLesiry is more prevalenr amon nonHispanic Llacks ar
43.2 percenr rhan Hispanics ar 31.0 percenr anc nonHispanic whires
ar 30.4 percenr, anc smokin is more prevalenr amon nonHispanic
Llacks ar 22.7 percenr rhan Hispanics ar 1c.8 percenr.
State Health Department Website: www.healrhyarkansas.com
ARKANSAS
A
R
K
A
N
S
A
S
www.americashealthrankings.org/AR
2 012
63
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
13.7
18.6
23.8
19.1
71.0
441
2.8
17.0
24.0
15.3
19.6
$106
90.8
6.8
118.2
51.9
0.12
8.9
3.8
3.9
16.8
5.0
250.4
165.0
6,190
0.14
0.26
2
28
5
3
42
35
3
46
40
50
44
12
23
9
22
9
24
17
25
25
42
3
23
6
9
15
22
3,894,000
6,764,000
2,529,000
5,428,000
Ranking: California is 22nd this year, unchanged from 2011.
Highlights:
Alrhouh lewer aculrs smoke in Calilornia as a percenrae ol
popularion comparec ro orher srares, 3. million aculrs srill smoke.
More rhan c.7 million aculrs in Calilornia are oLese, anc 5.4 million
lead a sedentary lifestyle.
More rhan 2.5 million aculrs in rhe srare have ciaLeres.
n rhe pasr year, rhe incicence ol inlecrious cisease increasec lrom
8.5 ro 17.0 cases per 100,000 popularion.
enrollees.
Health Disparities:
n Calilornia, oLesiry is more prevalenr amon nonHispanic Llacks
ar 37.7 percenr rhan nonHispanic whires ar 21.c percenr, secenrary
lilesryle is more prevalenr amon Hispanics ar 27.0 percenr rhan
nonHispanic whires ar 1c.1 percenr, anc smokin is more prevalenr
amon nonHispanic Llacks ar 17.8 percenr rhan nonHispanic whires
ar 12.c percenr anc Hispanics ar 12.2 percenr.
State Health Department Website: www.ccph.ca.ov
CALIFORNIA
C
A
L
I
F
O
R
N
I
A
www.americashealthrankings.org/CA
CA U.S.
11.6% 8.9%
21.1% 15.9%
$53,367 $50,054
2 012
64
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
18.3
20.1
20.7
16.5
77.6
321
4.0
11.1
15.5
6.7
14.3
$81
86.8
8.8
118.3
46.6
0.39
6.7
3.5
3.3
18.3
6.2
213.3
158.1
6,412
0.16
0.55
10
37
1
1
22
26
23
33
13
5
27
25
45
37
21
6
13
1
13
8
44
23
5
4
12
11
11
CO U.S.
8.4% 8.9%
15.1% 15.9%
$58,629 $50,054
711,000
805,000
260,000
641,000
Ranking: Colorado is 11th this year; it was 14th in 2011.
Highlights:
Coloraco has rhe lowesr oLesiry rare in rhe .S. ar 20.7 percenr
ol rhe popularion, wirh 805,000 oLese aculrs.
n rhe pasr year, rhe incicence ol inlecrious cisease cases rose
lrom 7.3 ro 11.1 cases per 100,000 popularion.
n rhe pasr year, rhe percenrae ol chilcren in poverry
cecreasec lrom 18.5 percenr ro 15.5 percenr ol persons uncer
rhe ae ol 18.
n rhe pasr 5 years, per capira puLlic healrh luncin rose lrom
$55 ro $81.
ceclinec lrom 57.2 ro 4c.c cischares per 1,000 Mecicare
enrollees.
n rhe pasr 10 years, rhe rare ol carciovascular cearhs ceclinec
Health Disparities:
n Coloraco, secenrary lilesryle is more prevalenr amon
Hispanics ar 27.7 percenr rhan nonHispanic whires ar 14.8
percenr, anc oLesiry is more prevalenr amon nonHispanic
Llacks ar 28.5 percenr rhan nonHispanic whires ar 18.7 percenr.
State Health Department Website: www.ccphe.srare.co.us

COLORADO
C
O
L
O
R
A
D
O
www.americashealthrankings.org/CO
2 012
65
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
17.1
17.9
24.5
25.5
75.4
281
3.7
5.3
14.3
9.3
9.9
$71
93.7
8.0
157.9
60.4
0.61
9.3
3.6
3.7
6.2
5.8
239.2
176.4
5,943
0.21
0.82
5
21
7
22
28
20
15
4
9
23
6
27
2
21
6
23
5
19
15
16
3
17
17
15
5
8
6
475,000
680,000
258,000
708,000
Ranking: Connecticut is 6th this year; it was 4th in 2011.
Highlights:
While Connecricur has one ol rhe lowesr smokin rares in rhe .S.,
475,000 aculrs srill smoke.
n rhe pasr 5 years, rhe hih school racuarion rare ceclinec
lrom 80.7 percenr ro 75.4 percenr ol incomin ninrh racers who
racuare in 4 years.
n rhe pasr 10 years, rhe percenrae ol chilcren in poverry increasec
lrom 8. percenr ro 14.3 percenr ol persons uncer rhe ae ol 18.
n rhe pasr 5 years, puLlic healrh luncin increasec lrom $57 ro $71
per person.
cecreasec lrom c7.3 ro c0.4 cischares per 1,000 Mecicare
enrollees.
n rhe pasr year, rhe inlanr morraliry rare cecreasec lrom c.3 ro 5.8
cearhs per 1,000 live Lirrhs.
Health Disparities:
n Connecricur, oLesiry is more prevalenr amon nonHispanic Llacks
ar 41.4 percenr rhan Hispanics ar 28.c percenr anc nonHispanic
whires ar 21.0 percenr, anc secenrary lilesryle is more prevalenr
amon Hispanics ar 27.5 percenr rhan nonHispanic whires ar
1. percenr.
State Health Department Website: www.cph.srare.cr.us
CONNECTICUT
C
O
N
N
E
C
T
I
C
U
T
www.americashealthrankings.org/CT
CT U.S.
8.9% 8.9%
15.4% 15.9%
$65,415 $50,054
2 012
66
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
21.8
20.3
28.8
27.0
73.7
621
2.9
4.3
22.3
11.0
10.7
$94
87.6
8.9
108.8
58.6
-0.08
9.7
3.4
3.6
6.6
8.1
258.1
195.7
8,015
0.02
-0.06
27
39
32
35
37
48
4
3
30
41
8
16
41
40
30
19
32
28
10
13
4
47
25
38
34
29
31
DE U.S.
7.5% 8.9%
13.2% 15.9%
$54,660 $50,054
153,000
202,000
68,000
190,000
Ranking: Delaware is 31st this year, unchanged from 2011.
Highlights:
n Delaware, 10,000 aculrs live a secenrary lilesryle, anc more rhan
200,000 adults are obese.
cecreasec lrom 72.1 ro 58.c cischares per 1,000 Mecicare
enrollees.
n rhe pasr 5 years, rhe levels ol air pollurion cecreasec lrom 14.7 ro
11.0 microrams ol lne parriculare per cuLic merer. r srill ranks 41sr
among states.
lrom 12.4 percenr ro 22.3 percenr ol persons uncer ae 18.
n rhe lasr 10 years, rhe rare ol carciovascular cearhs croppec lrom
331.4 ro 258.1 cearhs per 100,000 popularion.
Health Disparities:
n Delaware, oLesiry is more prevalenr amon nonHispanic Llacks
ar 41.1 percenr rhan Hispanics ar 28. percenr anc nonHispanic
whires ar 2c.4 percenr, secenrary lilesryle is more prevalenr amon
nonHispanic Llacks ar 32.1 percenr rhan nonHispanic whires ar 20.7
percenr, anc smokin is more prevalenr amon Hispanics ar 23.3
percenr rhan nonHispanic whires ar 18.3 percenr anc nonHispanic
Llacks ar 15.5 percenr.
State Health Department Website: www.chss.celaware.ov/chss
DELAWARE
D
E
L
A
W
A
R
E
www.americashealthrankings.org/DE
2 012
67
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
19.3
17.1
26.6
26.9
68.9
542
4.3
9.1
22.1
7.6
20.2
$61
91.3
8.7
108.4
65.3
-0.02
10.4
4.3
4.5
23.6
7.0
222.9
172.9
7,893
-0.12
-0.14
16
17
19
34
44
42
24
22
29
10
46
34
18
35
31
28
30
38
42
42
48
31
8
10
33
41
34
2,907,000
4,007,000
1,567,000
4,052,000
Ranking: Florida is 34th this year, unchanged from 2011.
Highlights:
n Florica, 4 million aculrs leac a secenrary lilesryle, anc 4 million
adults are obese.
n rhe pasr year, immunizarion coverae cecreasec lrom 4.7 percenr
ro 1.3 percenr ol chilcren aes 1 ro 35 monrhs.
n rhe pasr 5 years, rhe rare ol prevenraLle hospiralizarions cecreasec
lrom 70.1 ro c5.3 cischares per 1,000 Mecicare enrollees.
Ten years ao, 17.0 percenr ol rhe popularion was uninsurec, rocay ir
is 20.2 percenr.
lrom 14.c percenr ro 22.1 percenr ol persons uncer ae 18.
n rhe pasr 10 years, rhe rare ol cearhs lrom carciovascular cisease
cecreasec sinilcanrly lrom 311.2 ro 222. cearhs per 100,000
popularion.
Health Disparities:
n Florica, smokin is more prevalenr amon nonHispanic whires ar
18.5 percenr rhan Hispanics ar 11.5 percenr, oLesiry is more prevalenr
amon nonHispanic Llacks ar 3.1 percenr rhan Hispanics ar 2.1
percenr anc nonHispanic whires ar 24.7 percenr, anc secenrary
lilesryle is more prevalenr amon Hispanics ar 2. percenr rhan non
Hispanic whires ar 22.2 percenr.
State Health Department Website: www.coh.srare.l.us
FLORIDA
F
L
O
R
I
D
A
www.americashealthrankings.org/FL
FL U.S.
10.0% 8.9%
17.6% 15.9%
$45,105 $50,054
2 012
68
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
21.2
16.6
28.0
26.7
67.8
403
3.7
11.9
24.7
11.5
19.3
$58
93.6
9.6
102.3
68.4
-0.18
10.2
3.9
3.8
14.3
7.7
285.2
182.0
8,391
-0.08
-0.26
25
14
27
31
45
32
15
38
43
45
43
37
4
46
35
32
37
33
28
19
37
44
37
19
40
39
36
GA U.S.
10.1% 8.9%
17.1% 15.9%
$45,973 $50,054
1,553,000
2,051,000
747,000
1,956,000
Ranking: Georgia is 36th this year; it was 38th in 2011.
Highlights:
n Georia, 2 million aculrs are oLese anc almosr 750,000 aculrs
have ciaLeres.
n rhe pasr 5 years, rhe hih school racuarion rare increasec lrom
c1.2 percenr ro c7.8 percenr ol ninrh racers who racuare in 4
years.
While Georia is srill challenec Ly a hih inlanr morraliry rare, in
rhe pasr 10 years ir has ceclinec lrom 8.4 ro 7.7 cearhs per 1,000 live
Lirrhs.
cecreasec lrom 82.0 ro c8.4 cischares per 1,000 Mecicare
enrollees.
n rhe pasr 10 years, rhe rare ol uninsurec popularion increasec lrom
15.0 percenr ro 1.3 percenr.
Health Disparities:
n Georia, oLesiry is more prevalenr amon nonHispanic Llacks
ar 37.c percenr rhan nonHispanic whires ar 2c.1 percenr, smokin
is more prevalenr amon nonHispanic whires ar 18.8 percenr rhan
Hispanics ar 13.c percenr, anc secenrary lilesryle is more prevalenr
amon Hispanics ar 30.1 percenr rhan nonHispanic whires ar
22.c percenr.
State Health Department Website: www.healrh.srare.a.us

GEORGIA
G
E
O
R
G
I
A
www.americashealthrankings.org/GA
2 012
69
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
16.8
21.5
21.9
21.3
75.3
263
4.6
7.9
15.9
8.9
7.8
$236
92.9
8.3
138.0
25.0
0.68
8.4
2.8
3.0
7.1
5.8
211.0
150.5
6,763
0.30
0.98
3
43
2
6
30
14
27
13
14
19
2
1
9
30
8
1
2
11
1
2
6
18
3
2
18
2
2
180,000
234,000
90,000
228,000
Ranking: Hawaii is 2nd this year; it was 3rd in 2011.
Highlights:
Hawaii has one ol rhe lowesr oLesiry rares in rhe .S. However, rhere
are srill 234,000 oLese aculrs in rhe srare.
n rhe pasr 5 years, rhe levels ol air pollurion increasec lrom 4.c ro 8.
microrams ol lne parriculare per cuLic merer.
Currenrly, Hawaii has rhe lowesr rare ol prevenraLle hospiralizarions
in rhe .S. n rhe pasr 5 years, prevenraLle hospiralizarions cecreasec
n rhe pasr year, eoraphic cispariry wirhin rhe srare increasec lrom
c.3 percenr ro 7.1 percenr.
lrom 10.5 percenr ro 15. percenr ol persons uncer ae 18.
n rhe pasr 10 years, rhe inlanr morraliry rare ceclinec lrom 7.c ro 5.8
Health Disparities:
n Hawaii, smokin is more prevalenr amon nonHispanic Hawaiians/
Facilc slancers ar 23.1 percenr rhan nonHispanic whires ar 14.1
percenr, anc oLesiry is more prevalenr amon nonHispanic Hawaiians/
Facilc slancers ar 58.5 percenr rhan nonHispanic whires ar 1.4
percenr anc Hispanics ar 25.7 percenr.
State Health Department Website: hawaii.ov/healrh
HAWAII
H
A
W
A
I
I
www.americashealthrankings.org/H
HI U.S.
7.3% 8.9%
15.1% 15.9%
$59,047 $50,054
2 012
70
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
17.2
16.6
27.1
21.4
80.6
221
5.0
10.0
22.3
8.7
18.0
$126
87.3
6.8
77.5
43.6
0.29
9.4
3.9
3.9
12.2
5.7
233.1
170.0
6,773
0.13
0.43
6
14
21
7
13
7
32
29
30
18
37
5
43
8
50
4
18
21
28
25
27
16
13
7
19
17
17
ID U.S.
8.7% 8.9%
16.1% 15.9%
$47,459 $50,054
199,000
314,000
109,000
248,000
Ranking: Idaho is 17th this year; it was 15th in 2011.
Highlights:
While caho has one ol rhe lowesr smokin rares in rhe .S., close ro
200,000 aculrs srill smoke.
Lasr year, rhe incicence ol inlecrious cisease was 5.7 cases per
100,000 popularion, rhis year ir is 10.0 cases.
lrom 55.8 ro 43.c cischares per 1,000 Mecicare enrollees.
n rhe pasr 10 years, rhe inlanr morraliry rare ceclinec lrom 7.1 ro 5.7
Health Disparities:
n caho, smokin is more prevalenr amon nonHispanic Narive
Americans ar 31.7 percenr rhan Hispanics ar 14.2 percenr anc non
Hispanic whires ar 15. percenr, anc oLesiry is more prevalenr amon
nonHispanic Narive Americans ar 40.3 percenr rhan nonHispanic
whires ar 25.3 percenr anc Hispanics ar 33.3 percenr.
State Health Department Website: www.healrhancwellare.icaho.ov
IDAHO
I
D
A
H
O
www.americashealthrankings.org/ID
2 012
71
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
20.9
23.0
27.1
25.1
77.7
435
3.8
13.7
19.6
11.7
14.8
$67
90.3
8.3
130.4
75.0
-0.08
9.7
4.0
4.0
10.5
7.0
269.3
191.6
7,155
0.02
-0.06
22
47
21
19
21
34
18
41
21
46
31
30
26
28
11
40
33
28
31
29
18
29
31
35
23
27
30
2,042,000
2,648,000
948,000
2,453,000
Ranking: Illinois is 30th this year, unchanged from 2011.
Highlights:
Almosr 2.7 million aculrs in llinois are oLese, anc almosr 2.5 million
adults lead a sedentary lifestyle in the state.
n rhe pasr 5 years, air pollurion cecreasec lrom 14.5 ro 11.7
n rhe pasr year, rhe incicence ol inlecrious cisease rose lrom 11.1 ro
13.7 cases per 100,000 popularion.
lrom 14. percenr ro 1.c percenr ol persons uncer ae 18.
n rhe pasr 10 years, rhe inlanr morraliry rare cecreasec lrom 8.5 ro
7.0 cearhs per 1,000 live Lirrhs.
Health Disparities:
n llinois, oLesiry is more prevalenr amon nonHispanic Llacks ar 41.0
percenr rhan Hispanics ar 31.1 percenr anc nonHispanic whires ar 2c.0
percenr, smokin is more prevalenr amon nonHispanic Llacks ar
22.2 percenr rhan nonHispanic whires ar 17.0 percenr, anc secenrary
lilesryle is more prevalenr amon nonHispanic Llacks ar 2.5 percenr
rhan nonHispanic whires ar 23.3 percenr.
State Health Department Website: www.icph.srare.il.us
ILLINOIS
I
L
L
I
N
O
I
S
www.americashealthrankings.org/L
IL U.S.
9.7% 8.9%
17.0% 15.9%
$50,637 $50,054
2 012
72
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
25.6
17.8
30.8
29.2
75.2
315
4.8
11.7
23.6
13.1
12.7
$44
89.4
8.0
101.5
76.0
-0.28
10.2
4.2
4.2
8.6
7.4
285.4
200.1
8,357
-0.06
-0.34
44
19
42
42
33
23
30
37
38
49
14
47
30
22
38
41
43
33
40
35
11
35
38
41
38
36
41
IN U.S.
9.0% 8.9%
15.7% 15.9%
$44,445 $50,054
1,259,000
1,515,000
502,000
1,436,000
Ranking: Indiana is 41st this year; it was 37th in 2011.
Highlights:
nciana has one ol rhe hihesr prevalences ol smokin in rhe .S.,
wirh more rhan 1.25 million aculrs srill smokin.
More rhan a hall million aculrs in nciana have ciaLeres, anc more
rhan 1.5 million aculrs are oLese.
cecreasec lrom 83.2 ro 7c.0 cischares per 1,000 Mecicare
enrollees.
n rhe pasr 10 years, rhe percenrae ol chilcren in poverry more
rhan couLlec lrom 10.8 percenr ro 23.c percenr ol persons uncer
ae 18.
n rhe pasr year, rhe incicence ol inlecrious cisease rose lrom 7.8
ro 11.7 cases per 100,000 popularion.
Alrhouh nciana has one ol rhe lowesr amounrs ol puLlic healrh
luncin in rhe .S., ir has increasec lrom $33 ro $44 per person
over rhe pasr 5 years.
Health Disparities:
n nciana, smokin is more prevalenr amon nonHispanic Llacks ar
30.8 percenr rhan nonHispanic whires ar 21.4 percenr anc Hispanics
ar 20.1 percenr, anc oLesiry is more prevalenr amon nonHispanic
Llacks ar 37.2 percenr rhan nonHispanic whires ar 2.7 percenr.
State Health Department Website: www.in.ov/isch
INDIANA
I
N
D
I
A
N
A
www.americashealthrankings.org/IN
2 012
73
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
20.4
23.1
29.0
25.9
85.7
274
6.2
17.0
13.1
10.1
11.1
$55
88.9
7.0
84.3
60.4
0.06
8.2
3.0
3.0
9.5
5.1
258.4
182.7
6,632
0.24
0.30
21
48
33
24
5
18
40
46
6
34
10
40
32
12
46
22
27
8
3
2
12
6
26
22
15
6
20
477,000
678,000
192,000
606,000
Ranking: Iowa is 20th this year; it was 16th in 2011.
Highlights:
There are almosr c80,000 oLese aculrs in owa, anc more rhan
c00,000 aculrs leac a secenrary lilesryle in rhe srare.
n rhe pasr 10 years, rhe rare ol uninsurec popularion increasec
lrom 7. percenr ro 11.1 percenr.
enrollees.
100,000 popularion, rocay ir is 17.0 cases.
owa ranks lower lor cererminanrs rhan lor ourcomes, incicarin
rhar overall healrhiness may cecline over rime.
Health Disparities:
n owa, smokin is more prevalenr amon nonHispanic Llacks
ar 27.1 percenr rhan nonHispanic whires ar 1c.4 percenr anc
Hispanics ar 15.4 percenr, anc secenrary lilesryle is more
prevalenr amon Hispanics ar 34.3 percenr rhan nonHispanic
whires ar 23.8 percenr.
State Health Department Website: hrrp://www.icph.srare.ia.us/
IOWA
I
O
W
A
www.americashealthrankings.org/IA
IA U.S.
5.8% 8.9%
11.3% 15.9%
$50,219 $50,054
2 012
74
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
22.0
17.0
29.6
26.8
80.2
369
6.1
8.9
21.1
9.1
13.1
$45
91.3
7.1
101.7
66.8
0.09
9.5
3.3
3.4
11.9
7.1
260.3
182.1
7,581
0.06
0.15
30
16
37
33
15
29
39
20
25
20
18
46
18
16
37
31
26
22
9
9
25
32
28
20
26
23
24
KS U.S.
6.7% 8.9%
12.1% 15.9%
$46,147 $50,054
472,000
636,000
204,000
575,000
Ranking: Kansas is 24th this year; it was 25th in 2011.
Highlights:
Kansas has one ol rhe hihesr oLesiry rares in rhe .S., wirh
more rhan c30,000 oLese aculrs.
cecreasec lrom 80.8 ro cc.8 cischares per 1,000 Mecicare
enrollees.
n rhe pasr 5 years, puLlic healrh luncin increasec lrom $37 ro
$45 per person.
Ten years ao, 13.c percenr ol persons uncer ae 18 livec in
poverry, rhis year ir is 21.1 percenr.
The rare ol cearhs lrom carciovascular cisease ceclinec in rhe
lasr 10 years lrom 321.1 ro 2c0.3 cearhs per 100,000 popularion.
Health Disparities:
n Kansas, secenrary lilesryle is more prevalenr amon Hispanics
ar 34.1 percenr rhan nonHispanic Llacks ar 2c.5 percenr anc
nonHispanic whires ar 22.8 percenr, smokin is more prevalenr
amon nonHispanic Llacks ar 23.c percenr rhan Hispanics ar 17.1
percenr anc nonHispanic whires ar 1c. percenr, anc oLesiry is
more prevalenr amon nonHispanic Llacks ar 3.4 percenr rhan
nonHispanic whires ar 28. percenr.
State Health Department Website: www.kcheks.ov

KANSAS
K
A
N
S
A
S
www.americashealthrankings.org/KS
2 012
75
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
29.0
16.1
30.4
29.3
77.6
243
5.5
9.3
23.3
11.4
14.6
$81
92.2
9.0
102.1
102.8
-0.26
10.8
4.8
5.0
12.6
6.9
303.9
215.7
9,790
-0.22
-0.47
50
9
40
43
22
10
37
25
37
44
30
24
14
43
36
50
40
41
48
49
30
28
43
50
44
45
44
971,000
1,018,000
362,000
981,000
Ranking: Kentucky is 44th this year, unchanged from 2011.
Highlights:
Kenrucky has rhe hihesr smokin rare in rhe .S. ar 2.0
percenr ol rhe aculr popularion, wirh more rhan 70,000 aculr
smokers in the state.
There are more rhan 1 million oLese aculrs in Kenrucky.
The hih school racuarion rare improvec in rhe lasr 5 years,
lrom 73.0 percenr ro 77.c percenr ol incomin ninrh racers
who graduate within 4 years.
n rhe pasr 5 years, levels ol air pollurion cecreasec lrom 13.c ro
11.4 microrams ol parriculare per cuLic merer.
n rhe pasr year, immunizarion coverae increasec lrom 8.7
percenr ro 2.2 percenr ol chilcren aes 1 ro 35 monrhs.
While Kenrucky remains rhe srare wirh rhe hihesr rare ol
prevenraLle hospiralizarions, in rhe pasr 10 years, rhe rare
ceclinec lrom 115.3 ro 102.8 cischares per 1,000 Mecicare
enrollees.
Health Disparities:
n Kenrucky, oLesiry is more prevalenr amon nonHispanic Llacks
ar 42.5 percenr rhan nonHispanic whires ar 31.8 percenr.
State Health Department Website: www.chls.ky.ov
KENTUCKY
K
E
N
T
U
C
K
Y
www.americashealthrankings.org/KY
KY U.S.
9.5% 8.9%
15.6% 15.9%
$39,856 $50,054
2 012
76
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
25.7
16.1
33.4
33.8
67.3
549
8.1
16.9
30.5
9.5
20.3
$102
93.1
10.7
116.9
92.1
-0.66
11.8
4.4
4.5
11.9
8.9
318.2
207.9
10,262
-0.28
-0.94
45
9
49
47
46
44
47
45
49
26
47
13
7
49
24
48
50
46
44
42
25
49
46
48
47
49
49
888,000
1,155,000
408,000
1,168,000
Ranking: Louisiana is 49th this year; it was 50th in 2011.
Highlights:
Lesiry remains hih ar 33.4 percenr ol rhe aculr popularion,
wirh almosr 1.2 million oLese aculrs in Louisiana.
n rhe pasr year, rhe hih school racuarion rare increasec lrom
c3.5 percenr ro c7.3 percenr ol ninrh racers who racuare
within 4 years.
n rhe pasr 5 years, puLlic healrh luncin increasec lrom $c ro
$102 per person.
Lasr year, 17.2 percenr ol rhe popularion was uninsurec, rhis year
ir is 20.3 percenr.
While Kenrucky has one ol rhe hihesr rares ol prevenraLle
hospiralizarions in rhe .S., rhe rare ceclinec lrom 114.8 ro 2.1
cischares per 1,000 Mecicare enrollees over rhe lasr 10 years.
Health Disparities:
n Louisiana, oLesiry is more prevalenr amon nonHispanic Llacks
ar 41.c percenr rhan nonHispanic whires ar 2.3 percenr anc
Hispanics ar 28. percenr, anc secenrary lilesryle is more prevalenr
amon nonHispanic Llacks ar 35. percenr rhan nonHispanic
whires ar 2c.4 percenr anc Hispanics ar 25.1 percenr.
State Health Department Website: ww.chh.louisiana.ov/

LOUISIANA
L
O
U
I
S
I
A
N
A
www.americashealthrankings.org/LA
LA U.S.
7.8% 8.9%
13.4% 15.9%
$40,658 $50,054
2 012
77
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
22.8
17.3
27.8
23.0
79.9
122
3.2
6.7
17.7
7.8
9.7
$83
90.4
6.3
130.0
59.3
0.51
9.6
4.1
4.3
8.2
5.6
239.2
196.3
6,724
0.12
0.62
33
18
25
13
17
1
8
9
19
12
5
23
24
3
12
20
8
26
34
38
9
14
17
40
16
19
9
241,000
294,000
102,000
244,000
Ranking: Maine is 9th this year; it was 10th in 2011.
Highlights:
More rhan 240,000 aculrs smoke in Maine, anc almosr 300,000
aculrs are oLese.
n rhe pasr year, puLlic healrh luncin cecreasec lrom $8c ro $83
per person.
n rhe pasr 5 years, rhe inlanr morraliry rare cecreasec lrom c.3 ro
5.c cearhs per 1,000 live Lirrhs.
n rhe pasr 10 years, rhe percenrae ol chilcren in poverry
increasec lrom 11.8 percenr ro 17.7 percenr ol persons uncer
ae 18.
cecreasec lrom 75. ro 5.3 cischares per 1,000 Mecicare
enrollees.
Maine ranks hiher lor cererminanrs rhan lor ourcomes, incicarin
rhar overall healrhiness may improve over rime.
Health Disparities:
n Maine, oLesiry is more prevalenr amon nonHispanics whires
ar 27.0 percenr rhan Hispanics ar 20. percenr, secenrary lilesryle
is more prevalenr amon nonHispanic whires ar 21.8 percenr rhan
Hispanics ar 1c.7 percenr, anc smokin is more prevalenr amon
Hispanics ar 25.1 percenr rhan nonHispanic whires ar 17.4 percenr.
State Health Department Website: www.maine.ov/chhs
MAINE
M
A
I
N
E
www.americashealthrankings.org/ME
ME U.S.
8.0% 8.9%
15.1% 15.9%
$49,693 $50,054
2 012
78
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
19.1
18.0
28.3
26.2
80.1
548
3.8
8.8
11.3
10.9
13.3
$96
92.8
8.8
173.8
62.7
0.33
9.5
3.7
3.2
13.0
7.6
278.5
186.9
7,521
0.01
0.34
11
23
29
25
16
43
18
19
2
40
19
14
10
38
2
26
15
22
19
6
35
41
36
32
25
30
19
MD U.S.
7.0% 8.9%
12.6% 15.9%
$68,876 $50,054
856,000
1,268,000
426,000
1,174,000
Ranking: Maryland is 19th this year; it was 24th in 2011.
Highlights:
While Marylanc has one ol rhe lowesr smokin rares in rhe .S.,
more rhan 850,000 aculrs srill smoke.
More rhan 1.2 million aculrs are oLese, anc almosr 1.2 million
aculrs live a secenrary lilesryle.
n rhe pasr year, rhe percenrae ol chilcren in poverry cecreasec
enrollees.
Marylanc ranks hiher lor cererminanrs rhan lor ourcomes,
incicarin rhar overall healrhiness may improve over rime.
Health Disparities:
n Marylanc, smokin is more prevalenr amon nonHispanic
Llacks ar 17.1 percenr rhan Hispanics ar 10.4 percenr, oLesiry is
more prevalenr amon nonHispanic Llacks ar 3c.7 percenr rhan
nonHispanic whires ar 24.4 percenr, anc secenrary lilesryle is
more prevalenr amon nonHispanic Llacks ar 2.1 percenr rhan
nonHispanic whires ar 20.7 percenr.
State Health Department Website: www.chmh.srare.mc.us

MARYLAND
M
A
R
Y
L
A
N
D
www.americashealthrankings.org/MD
www.dhmh.maryland.gov
2 012
79
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
18.2
20.6
22.7
23.5
83.3
467
2.4
9.8
12.6
8.4
4.5
$120
93.0
7.7
194.5
72.8
0.62
8.0
3.6
3.6
7.0
5.1
231.1
184.4
5,894
0.26
0.88
9
40
3
14
8
38
1
28
5
15
1
9
8
20
1
38
4
6
15
13
5
5
10
25
4
3
4
943,000
1,176,000
415,000
1,218,000
Ranking: Massachusetts is 4th this year; it was 7th in 2011.
Highlights:
Massachuserrs has one ol rhe lowesr oLesiry rares in rhe .S. ar
22.7 percenr ol rhe aculr popularion, yer almosr 1.2 million aculrs
are oLese in rhe srare.
n rhe pasr year, rhe incicence ol inlecrious cisease cecreasec lrom
13.5 ro .8 cases per 100,000 popularion.
n rhe pasr 5 years, rhe rare ol uninsurec popularion cecreasec
lrom .8 percenr ro 4.5 percenr.
Ten years ao, rhe rare ol prevenraLle hospiralizarions was 84.1
cischares per 1,000 Mecicare enrollees, rocay ir is 72.8 cischares.
n rhe pasr 10 years, rhe rare ol cancer cearhs cecreasec lrom
20c. ro 184.4 cearhs per 100,000 popularion.
Health Disparities:
n Massachuserrs, secenrary lilesryle is more prevalenr amon Hispanics
ar 35.5 percenr rhan nonHispanic Llacks ar 2c.2 percenr anc non
Hispanic whires ar 18.c percenr, anc oLesiry is more prevalenr amon
nonHispanic Llacks ar 31.5 percenr rhan nonHispanic whires ar 22.1
percent.
State Health Department Website: www.mass.ov/cph
MASSACHUSETTS
M
A
S
S
A
C
H
U
S
E
T
T
S
www.americashealthrankings.org/MA
MA U.S.
7.3% 8.9%
14.3% 15.9%
$63,313 $50,054
2 012
80
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
23.3
19.7
31.3
23.6
75.3
490
3.7
15.4
22.7
9.5
12.7
$56
87.0
8.4
117.4
69.8
-0.23
10.0
4.2
4.1
9.5
7.4
303.2
192.2
7,807
-0.04
-0.27
40
35
46
15
30
40
15
42
35
26
14
39
44
32
23
35
38
30
40
32
12
36
42
36
31
33
37
MI U.S.
10.2% 8.9%
18.8% 15.9%
$48,879 $50,054
1,766,000
2,373,000
758,000
1,789,000
Ranking: Michigan is 37th this year; it was 33rd in 2011.
Highlights:
Alrhouh Michian has one ol rhe lower rares ol secenrary
lilesryle in rhe .S., more rhan 1.7 million aculrs live a
secenrary lilesryle anc almosr 2.4 million aculrs are oLese in
the state.
Lasr year, 2. percenr ol chilcren aes 1 ro 35 monrhs
receivec immunizarions, rhis year ir is 87.0 percenr.
n rhe pasr 5 years, air pollurion cecreasec lrom 12. ro .5
cecreasec lrom 77.c ro c.8 cischares per 1,000 Mecicare
enrollees
increasec lrom 12.4 percenr ro 22.7 percenr ol persons uncer
ae 18.
Health Disparities:
n Michian, oLesiry is more prevalenr amon nonHispanic
Llacks ar 42.1 percenr rhan nonHispanic whires ar 2.2 percenr,
anc secenrary lilesryle is more prevalenr amon nonHispanic
Llacks ar 2.c percenr rhan nonHispanic whires ar 22.7 percenr.
State Health Department Website: www.michian.ov/mcch
MICHIGAN
M
I
C
H
I
G
A
N
www.americashealthrankings.org/MI
2 012
81
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
19.1
22.1
25.7
21.9
87.4
236
2.7
24.3
13.3
8.2
9.5
$43
93.2
6.4
141.6
50.6
0.51
7.3
3.1
2.9
11.0
5.3
195.9
177.7
5,621
0.31
0.82
11
44
15
8
3
9
2
50
7
13
4
48
6
6
7
8
7
3
5
1
21
8
1
16
1
1
5
777,000
1,045,000
297,000
891,000
Ranking: Minnesota is 5th this year; it was 6th in 2011.
Highlights:
Minnesora's secenrary lilesryle anc ciaLeres rares are amon rhe
lowesr in rhe .S. However, 81,000 aculrs live a secenrary lilesryle
anc almosr 300,000 aculrs have ciaLeres in rhe srare.
n rhe pasr year, immunizarion coverae increasec lrom 0. percenr
cecreasec lrom c5.c ro 50.c cischares per 1,000 Mecicare
enrollees.
n rhe pasr 5 years, puLlic healrh luncin cecreasec lrom $c2 ro $43
per person.
lrom 270.4 ro 15. cearhs per 100,000 popularion.
n rhe pasr 10 years, rhe percenrae ol chilcren in poverry has
increasec lrom 8.1 percenr ro 13.3 percenr ol persons uncer ae 18.
Health Disparities:
n Minnesora, secenrary lilesryle is more prevalenr amon non
Hispanic Llacks ar 2.4 percenr rhan nonHispanic whires ar 1c.8
percenr, anc smokin is more prevalenr amon nonHispanic Llacks ar
21.2 percenr rhan nonHispanic whires ar 15.4 percenr.
State Health Department Website: www.healrh.srare.mn.us
MINNESOTA
M
I
N
N
E
S
O
T
A
www.americashealthrankings.org/MN
MN U.S.
6.5% 8.9%
12.8% 15.9%
$57,820 $50,054
2 012
82
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
26.0
14.2
34.9
36.0
62.0
270
6.9
11.2
24.4
10.0
18.6
$63
88.2
12.1
81.4
91.3
-0.63
12.4
4.4
4.6
12.7
10.0
357.4
207.0
11,113
-0.31
-0.94
46
6
50
50
49
16
41
34
41
31
42
33
38
50
48
47
49
50
44
45
32
50
50
47
50
50
49
MS U.S.
10.5% 8.9%
16.4% 15.9%
$41,090 $50,054
579,000
778,000
276,000
802,000
Ranking: Mississippi is 49th this year, unchanged from 2011.
Highlights:
Mississippi ranks lasr in rhe .S. lor secenrary lilesryle, oLesiry, anc
ciaLeres. More rhan 800,000 aculrs live a secenrary lilesryle, almosr
780,000 aculrs are oLese anc almosr 280,000 aculrs have ciaLeres in
the state.
Lasr year, c3. percenr ol incomin ninrh racers racuarec wirhin 4
years, rhis year ir is c2.0 percenr.
n rhe pasr year, immunizarion coverae cecreasec lrom 2.7 percenr
n rhe pasr year, rhe rare ol uninsurec popularion cecreasec lrom 1.2
percenr ro 18.c percenr.
The percenrae ol chilcren uncer ae 18 livin in poverry cecreasec
lrom 33.7 percenr ro 24.4 percenr in rhe lasr year.
Health Disparities:
n Mississippi, oLesiry is more prevalenr amon nonHispanic Llacks ar
43.2 percenr rhan Hispanics ar 33.4 percenr anc nonHispanic whires ar
30. percenr, secenrary lilesryle is more prevalenr amon nonHispanic
Llacks ar 37.2 percenr rhan Hispanics ar 27.3 percenr, anc smokin
is more prevalenr amon nonHispanic Llacks ar 24.1 percenr rhan
Hispanics ar 18.8 percenr.
State Health Department Website: www.msch.srare.ms.us
MISSISSIPPI
M
I
S
S
I
S
S
I
P
P
I
www.americashealthrankings.org/MS
2 012
83
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
25.0
19.2
30.3
28.4
83.1
455
4.9
16.8
23.1
10.3
14.4
$46
86.5
8.2
107.2
73.0
-0.32
10.2
4.1
4.2
12.4
7.2
298.3
196.1
8,409
-0.09
-0.40
42
33
39
41
9
37
31
43
36
35
29
44
46
23
32
39
44
33
34
35
29
33
41
39
41
40
42
1,150,000
1,393,000
469,000
1,306,000
Ranking: Missouri is 42nd this year; it was 40th in 2011.
Highlights:
n Missouri, more rhan 1.1 million aculrs smoke.
increasec lrom 20.5 percenr ro 23.1 percenr ol persons
uncer ae 18. Chilcren in poverry was 12.5 percenr in 2002.
Air pollurion cecreasec in rhe pasr 5 years, lrom 12.2 ro 10.3
n rhe pasr 10 years, rhe rare ol uninsurec popularion
increasec lrom .4 percenr ro 14.4 percenr.
FuLlic healrh luncin, in rhe pasr 5 years, increasec lrom $40
ro $4c per person.
Health Disparities:
n Missouri, secenrary lilesryle is more prevalenr amon
nonHispanic Llacks ar 37.5 percenr rhan nonHispanic whires
ar 25.7 percenr, anc oLesiry is more prevalenr amon non
Hispanic Llacks ar 3.3 percenr rhan nonHispanic whires ar
30.1 percenr anc Hispanics ar 2.1 percenr.
State Health Department Website: www.chss.mo.ov
MISSOURI
M
I
S
S
O
U
R
I
www.americashealthrankings.org/MO
MO U.S.
8.4% 8.9%
14.4% 15.9%
$45,774 $50,054
2 012
84
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
22.1
20.8
24.6
24.4
82.0
272
8.1
10.2
25.1
7.6
18.2
$89
85.3
7.5
97.9
56.2
0.01
8.0
3.7
4.2
16.8
6.4
236.5
174.6
7,836
0.03
0.04
31
41
10
18
11
17
47
30
45
10
39
19
49
18
40
15
29
6
19
35
42
25
15
14
32
26
29
MT U.S.
7.3% 8.9%
15.3% 15.9%
$40,277 $50,054
171,000
191,000
62,000
189,000
Ranking: Montana is 29th this year; it was 26th in 2011.
Highlights:
Monrana's oLesiry anc ciaLeres rares are amon rhe lowesr in rhe
.S. However, rhere are more rhan 10,000 oLese aculrs anc more
rhan c0,000 aculrs wirh ciaLeres in rhe srare.
n rhe pasr year, rhe percenrae ol chilcren in poverry increasec lrom
1.2 percenr ro 25.1 percenr ol persons uncer ae 18. Chilcren in
poverry was 15.5 percenr in 2002.
FuLlic healrh luncin increasec lrom $c ro $8 per person in rhe
pasr 5 years.
cecreasec lrom 70.3 ro 5c.2 cischares per 1,000 Mecicare enrollees.
n rhe pasr 5 years, rhe inlanr morraliry rare increasec lrom 5.5 ro c.4
Health Disparities:
n Monrana, smokin is more prevalenr amon nonHispanic Narive
Americans ar 45.8 percenr rhan nonHispanic whires ar 15.5 percenr
anc Hispanics ar 2.4 percenr, anc oLesiry is more prevalenr amon
nonHispanics Narive Americans ar 40.7 percenr rhan nonHispanic
whires ar 22.7 percenr.
State Health Department Website: www.cphhs.mr.ov
MONTANA
M
O
N
T
A
N
A
www.americashealthrankings.org/MT
2 012
85
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
20.0
22.7
28.4
26.3
82.9
280
5.2
11.4
14.5
8.2
12.8
$83
94.2
7.1
116.7
65.4
0.31
8.4
3.1
3.2
12.7
5.4
239.3
178.2
6,520
0.20
0.51
19
46
30
28
10
19
33
36
10
13
16
22
1
17
25
29
17
11
5
6
32
12
19
17
13
9
15
277,000
393,000
116,000
364,000
Ranking: Nebraska is 15th this year; it was 18th in 2011.
Highlights:
n NeLraska, more rhan 30,000 aculrs are oLese anc more rhan
3c0,000 aculrs live a secenrary lilesryle.
n rhe pasr lve years, rhe hih school racuarion rare cecreasec lrom
87.c percenr ro 82. percenr ol incomin ninrh racers who racuare
within 4 years.
Alrhouh NeLraska has a hih incicence ol inlecrious cisease, rhe
rare cecreasec in rhe lasr year lrom 14.1 ro 11.4 cases per 100,000
popularion.
8.5 percenr ro 12.8 percenr.
lrom 73.3 ro c5.4 cischares per 1,000 Mecicare enrollees.
n rhe pasr year, rhe inlanr morraliry rare cecreasec lrom c.1 ro 5.4
cearhs per 1,000 live Lirrhs. n 2002 rhe rare was 7.1 cearhs.
Health Disparities:
n NeLraska, secenrary lilesryle is more prevalenr amon nonHispanic
Llacks ar 40.8 percenr rhan nonHispanic whires ar 23.2 percenr, oLesiry
is more prevalenr amon nonHispanic Llacks ar 3.c percenr rhan non
Hispanic whires ar 27.0 percenr, anc smokin is more prevalenr amon
nonHispanic Llacks ar 22.c percenr rhan Hispanics ar 1c.5 percenr anc
nonHispanic whires ar 1c.3 percenr.
State Health Department Website: www.chhs.ne.ov/
NEBRASKA
N
E
B
R
A
S
K
A
www.americashealthrankings.org/NE
NE U.S.
4.5% 8.9%
8.9% 15.9%
$55,616 $50,054
2 012
86
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
22.9
18.6
24.5
24.3
56.3
661
4.7
6.0
20.6
8.4
22.0
$39
87.6
8.3
83.6
58.1
-0.25
10.3
3.9
3.9
19.2
5.6
273.2
184.3
8,159
-0.03
-0.28
34
28
7
17
50
50
28
8
23
15
49
49
40
27
47
16
39
37
28
25
45
15
33
24
35
32
38
NV U.S.
13.1% 8.9%
22.7% 15.9%
$47,043 $50,054
472,000
505,000
212,000
500,000
Ranking: Nevada is 38th this year; it was 39th in 2011.
Highlights:
Nevaca's oLesiry rare is lower rhan mosr orher srares.
However, more rhan 500,000 aculrs are oLese in rhe srare.
cecreasec lrom 23.c percenr ro 20.c percenr ol persons uncer
ae 18. Chilcren in poverry was 8.7 percenr in 2002.
n rhe pasr year, rhe incicence ol inlecrious cisease increasec
lrom 4.8 ro c.0 cases per 100,000 popularion.
n rhe pasr 5 years, rhe rare ol prevenraLle hospiralizarion
cecreasec lrom c5.3 ro 58.1 cischares per 1,000 Mecicare
enrollees.
increasec lrom 15. percenr ro 22.0 percenr ol rhe popularion.
Ten years ao, rhe inlanr morraliry rare was c.5 cearhs per
1,000 live Lirrhs, rhis year ir is 5.c cearhs.
Health Disparities:
n Nevaca, oLesiry is more prevalenr amon nonHispanic
Llacks ar 30.4 percenr rhan Hispanics ar 23.4 percenr.
State Health Department Website: hrrp://chhs.nv.ov/

NEVADA
N
E
V
A
D
A
www.americashealthrankings.org/NV
2 012
87
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
19.4
18.7
26.2
22.5
84.3
167
3.1
5.5
8.6
7.5
11.3
$58
90.3
6.8
133.0
56.0
0.65
8.7
4.1
3.8
7.2
4.4
231.1
184.4
5,840
0.25
0.90
17
30
16
11
7
3
6
5
1
9
11
36
25
11
10
14
3
15
34
19
7
1
10
25
3
4
3
201,000
272,000
90,000
234,000
Ranking: New Hampshire is 3rd this year; it was 2nd in 2011.
Highlights:
New Hampshire has one ol rhe lowesr secenrary lilesryle
rares in rhe .S. ar 22.5 percenr ol rhe popularion, wirh
234,000 secenrary aculrs.
n rhe pasr year, rhe incicence ol inlecrious cisease
cecreasec lrom c.8 ro 5.5 cases per 100,000 popularion.
Air pollurion cecreasec in rhe pasr 5 years, lrom .1 ro 7.5
increasec lrom 8.5 percenr ro 11.3 percenr.
Since 10, rhe inlanr morraliry rare cecreasec lrom 8.4
ro 4.4 cearhs per 1,000 live Lirrhs anc is rhe lowesr amon
all srares.
Health Disparities:
n New Hampshire, oLesiry is more prevalenr amon
nonHispanic whires ar 2c.2 percenr rhan Hispanic ar 21.0
percent.
State Health Department Website: www.chhs.srare.nh.us
NEWHAMPSHIRE
N
E
W
H
A
M
P
S
H
I
R
E
www.americashealthrankings.org/NH
NH U.S.
5.4% 8.9%
11.3% 15.9%
$65,880 $50,054
2 012
88
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
16.8
18.2
23.7
26.4
85.3
308
3.5
5.9
17.4
9.2
15.5
$65
91.1
8.2
137.7
68.8
0.45
8.8
3.4
3.5
10.6
5.3
258.4
182.6
6,173
0.20
0.64
3
25
4
30
6
21
12
6
17
21
33
32
21
26
9
33
10
16
10
12
19
9
26
21
7
10
8
NJ U.S.
9.4% 8.9%
16.0% 15.9%
$62,338 $50,054
1,139,000
1,606,000
596,000
1,789,000
Ranking: New Jersey is 8th this year; it was 17th in 2011.
Highlights:
New Jersey has one ol rhe lowesr smokin rares in rhe .S.,
however, more rhan 1.1 million aculrs srill smoke in rhe srare.
n rhe pasr year, rhe percenrae ol chilcren in poverry rose
lrom 12.8 percenr ro 17.4 percenr ol persons uncer ae 18. n
2002, ir was .1 percenr.
FuLlic healrh luncin cecreasec lrom $c ro $c5 per person in
rhe lasr year.
ceclinec lrom 83. ro c8.8 cischares per 1,000 Mecicare
enrollees.
n rhe pasr 10 years, rhe inlanr morraliry rare cecreasec lrom
c.5 ro 5.3 cearhs per 1,000 live Lirrhs.
Health Disparities:
n New Jersey, secenrary lilesryle is more prevalenr amon
Hispanics ar 3c. percenr rhan nonHispanic whires ar 22.7
percenr, anc oLesiry is more prevalenr amon nonHispanic
Llacks ar 3c.0 percenr rhan Hispanics ar 27.8 percenr anc non
State Health Department Website: www.srare.n|.us/healrh

NEW JERSEY
N
E
W

J
E
R
S
E
Y
www.americashealthrankings.org/NJ
2 012
89
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
21.5
16.4
26.3
25.3
64.8
589
8.8
8.9
31.7
6.1
20.5
$122
91.3
8.7
111.5
54.9
-0.12
10.0
4.0
4.4
14.5
5.4
222.3
161.1
8,385
0.05
-0.07
26
11
17
21
48
45
50
20
50
4
48
8
17
36
28
12
34
30
31
40
38
13
7
5
39
24
32
336,000
411,000
156,000
395,000
Ranking: New Mexico is 32nd this year, unchanged from 2011.
Highlights:
Alrhouh New Mexico has a lower rare ol secenrary lilesryle
rhan mosr orher srares in rhe .S., rhere are srill 35,000
secenrary aculrs in rhe srare.
Lasr year, 27.c percenr ol persons uncer ae 18 livec in
poverry, rhis year ir is 31.7 percenr.
enrollees.
n rhe pasr 10 years, rhe inlanr morraliry rare cecreasec lrom
c.8 ro 5.4 cearhs per 1,000 live Lirrhs.
New Mexico ranks lower lor cererminanrs rhan lor ourcomes,
incicarin rhar overall healrhiness may cecline over rime.
Health Disparities:
n New Mexico, oLesiry is more prevalenr amon Hispanics ar
30.7 percenr rhan nonHispanic whires ar 20.c percenr, smokin
is more prevalenr amon nonHispanic Llacks ar 23.c percenr
rhan nonHispanic whires ar 15. percenr, anc secenrary lilesryle
is more prevalenr amon Hispanics ar 2c.3 percenr rhan non
State Health Department Website: www.healrh.srare.nm.us
NEW MEXICO
N
E
W

M
E
X
I
C
O
www.americashealthrankings.org/NM
NM U.S.
7.4% 8.9%
14.7% 15.9%
$41,982 $50,054
2 012
90
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
18.1
19.6
24.5
26.3
73.5
392
3.2
9.7
22.6
9.2
13.6
$124
88.8
8.2
160.2
66.3
0.25
10.5
3.7
4.0
9.8
5.4
285.9
170.5
6,183
0.15
0.40
8
34
7
28
39
31
8
26
33
21
20
6
34
25
5
30
19
40
19
29
14
11
39
8
8
14
18
NY U.S.
8.1% 8.9%
14.3% 15.9%
$50,636 $50,054
2,747,000
3,719,000
1,594,000
3,992,000
Ranking: New York is 18th this year; it was 20th in 2011.
Highlights:
New York has one ol rhe lowesr oLesiry rares in rhe .S. ar 24.5
percenr ol rhe aculr popularion, however, more rhan 3.7 million
aculrs are oLese in rhe srare.
Alrhouh hih school racuarion rares remain a challene
lor rhe srare, rhe percenrae ol incomin ninrh racers who
racuare in 4 years increasec in rhe pasr 5 years lrom c0.
percenr ro 73.5 percenr.
n rhe pasr 5 years, air pollurion cecreasec lrom 11.8 ro .2
Five years ao, rhe eoraphic cispariry wirhin rhe srare was 7.5,
rhis year ir is .8, incicarin rhar healrh now varies more wicely
amon counries wirhin rhe srare.
n rhe pasr 10 years, rhe rare ol uninsurec popularion cecreasec
lrom 15.5 percenr ro 13.c percenr.
Health Disparities:
n New York, oLesiry is more prevalenr amon nonHispanic Llacks
ar 32.2 percenr rhan nonHispanic whires ar 23.8 percenr.
State Health Department Website: www.healrh.srare.ny.us

NEW YORK
N
E
W

Y
O
R
K
www.americashealthrankings.org/NY
2 012
91
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
21.8
15.2
29.1
26.7
75.1
363
4.3
8.7
23.9
10.0
16.7
$51
89.5
9.1
114.7
62.6
-0.04
10.9
3.7
3.8
11.8
8.1
273.0
190.5
8,244
-0.07
-0.11
27
7
34
31
35
27
24
18
39
31
34
42
28
44
26
25
31
42
19
19
24
46
32
33
37
38
33
1,606,000
2,144,000
803,000
1,967,000
Ranking: North Carolina is 33rd this year; it was 35th in 2011.
Highlights:
DiaLeres remains hih ar 10. percenr ol rhe aculr popularion.
More rhan 800,000 aculrs have ciaLeres in rhe srare.
Lasr year, 27.c percenr ol persons uncer ae 18 livec in poverry,
rhis year ir is 23. percenr.
n rhe pasr 5 years, air pollurion cecreasec lrom 13.0 ro 10.0
cecreasec lrom 75.1 ro c2.c cischares per 1,000 Mecicare
enrollees.
The rare ol uninsurec popularion increasec lrom 13.4 percenr ro
1c.7 percenr in rhe pasr 10 years.
mmunizarion coverae croppec Lelow 0.0 percenr ol chilcren
aes 1 ro 35 monrhs lor rhe lrsr rime in eihr years.
Health Disparities:
n Norrh Carolina, oLesiry is more prevalenr amon nonHispanic
Llacks ar 42. percenr rhan nonHispanic whires ar 2c.5 percenr anc
Hispanics ar 24.8 percenr, smokin is more prevalenr amon non
Hispanic Llacks ar 20. percenr rhan Hispanics ar 13. percenr, anc
secenrary lilesryle is more prevalenr amon nonHispanic Llacks ar
32.c percenr rhan nonHispanic whires ar 24.4 percenr.
State Health Department Website: www.chhs.srare.nc.us
NORTH CAROLINA
N
O
R
T
H

C
A
R
O
L
I
N
A
www.americashealthrankings.org/NC
NC U.S.
10.5% 8.9%
17.9% 15.9%
$45,206 $50,054
2 012
92
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
21.9
23.8
27.8
27.1
87.4
225
7.6
7.8
11.9
5.6
11.3
$78
93.3
6.7
121.5
59.4
0.43
8.2
2.8
3.1
19.8
6.0
235.6
173.3
7,196
0.12
0.54
29
49
25
38
3
8
45
12
4
2
11
26
5
7
17
21
11
8
1
4
47
19
14
11
24
19
12
ND U.S.
3.6% 8.9%
6.6% 15.9%
$56,361 $50,054
117,000
148,000
44,000
144,000
Ranking: North Dakota is 12th this year; it was 11th in 2011.
Highlights:
Norrh Dakora has one ol rhe lowesr ciaLeres rares in rhe .S.,
however, more rhan 40,000 aculrs have ciaLeres in rhe srare.
n rhe pasr year, rhe percenrae ol chilcren in poverry cecreasec lrom
1c.1 percenr ro 11. percenr ol persons uncer ae 18. This is one ol
rhe lowesr percenraes ol chilcren in poverry in rhe .S.
.7 percenr ro 11.3 percenr.
Ten years ao, rhe inlanr morraliry rare was 7.4 cearhs per 1,000 live
Lirrhs, rhis year ir is c.0 cearhs.
Norrh Dakora ranks hiher lor cererminanrs rhan lor ourcomes,
incicarin rhar overall healrhiness may improve over rime.
Health Disparities:
n Norrh Dakora, oLesiry is more prevalenr amon nonHispanic Narive
Americans ar 45.3 percenr anc Hispanics ar 40.8 percenr rhan non
Hispanic whires ar 27.5 percenr, secenrary lilesryle is more prevalenr
amon Hispanics ar 4.5 percenr rhan nonHispanic Narive Americans
ar 28.3 percenr anc nonHispanic whires ar 25.0 percenr, anc smokin is
more prevalenr amon nonHispanic Narive Americans ar 47.2 percenr
rhan nonHispanic whires ar 1c.1 percenr anc Hispanics ar 32.8 percenr.
State Health Department Website: www.nchealrh.ov
NORTH DAKOTA
N
O
R
T
H
D
A
K
O
T
A
www.americashealthrankings.org/ND
2 012
93
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
25.1
20.1
29.7
27.0
79.6
315
3.3
16.8
21.1
12.0
13.7
$51
92.3
8.6
120.9
78.5
-0.18
10.0
4.1
4.1
9.8
7.7
287.6
201.8
8,219
-0.07
-0.25
43
37
38
35
18
25
10
43
25
47
21
43
13
34
19
42
36
30
34
32
14
42
40
43
36
37
35
2,222,000
2,629,000
885,000
2,390,000
Ranking: Ohio is 35th this year; it was 36th in 2011.
Highlights:
wirh more rhan 2.2 million aculr smokers.
Lasr year, puLlic healrh luncin was $45 per person, rhis year ir is
$51 per person.
n rhe pasr 5 years, air pollurion cecreasec lrom 13. ro 12.0
enrollees, however, ir srill remains hih comparec ro orher srares.
lrom 10.7 percenr ro 13.7 percenr. Lasr year ir was 13.7 percenr.
Health Disparities:
n hio, oLesiry is more prevalenr amon nonHispanic Llacks
ar 42.5 percenr rhan Hispanics ar 33.1 percenr anc nonHispanic
whires ar 28.7 percenr, anc secenrary lilesryle is more prevalenr
amon nonHispanic Llacks ar 35.0 percenr rhan Hispanics ar 27.c
percenr anc nonHispanic whires ar 25.3 percenr.
State Health Department Website: www.och.ohio.ov
OHIO
O
H
I
O
www.americashealthrankings.org/H
OH U.S.
8.7% 8.9%
14.7% 15.9%
$44,648 $50,054
2 012
94
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
26.1
16.5
31.1
31.2
77.3
480
7.0
7.1
20.7
9.9
17.1
$95
91.2
8.4
80.2
81.0
-0.26
11.1
4.5
4.4
10.9
7.5
330.7
200.4
10,205
-0.20
-0.46
47
12
45
45
25
39
42
11
24
29
35
15
20
31
49
45
42
43
46
40
20
39
48
42
46
44
43
OK U.S.
6.2% 8.9%
10.7% 15.9%
$48,455 $50,054
745,000
888,000
317,000
891,000
Ranking: Oklahoma is 43rd this year; it was 46th in 2011.
Highlights:
Smokin remains hih ar 2c.1 percenr ol aculrs, 745,000 aculrs
still smoke in Oklahoma.
Lasr year, 25.0 percenr ol persons uncer ae 18 livec in poverry,
rhis year ir is 20.7 percenr.
n rhe pasr year, puLlic healrh luncin ceclinec lrom $113 ro
$5 per person.
cecreasec lrom 5. ro 81.0 cischares per 1,000 Mecicare
enrollees, however, ir srill ranks very hih amon all srares.
n rhe pasr 10 years, rhe prevalence ol low Lirrhweihr inlanrs
increasec lrom 7.4 percenr ro 8.4 percenr ol live Lirrhs.
n rhe pasr 10 years, rhe inlanr morraliry rare cecreasec lrom 8.5
ro 7.5 cearhs per 1,000 live Lirrhs.
Health Disparities:
n klahoma, smokin is more prevalenr amon nonHispanic
Llacks ar 31. percenr rhan nonHispanic whires ar 23.3 percenr
anc Hispanics ar 20.7 percenr, anc oLesiry is more prevalenr
amon nonHispanic Llacks ar 42. percenr rhan nonHispanic
whires ar 2. percenr anc Hispanics ar 2.7 percenr.
State Health Department Website: www.ok.ov/healrh

OKLAHOMA
O
K
L
A
H
O
M
A
www.americashealthrankings.org/OK
2 012
95
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
19.7
16.5
26.7
19.8
76.5
252
3.1
9.2
20.3
7.3
14.9
$59
85.7
6.3
128.1
42.9
0.39
9.3
3.8
4.6
11.1
5.0
231.4
184.7
6,741
0.13
0.53
18
12
20
4
27
12
6
24
22
8
32
35
47
4
13
3
12
19
25
45
22
2
12
27
17
16
13
593,000
803,000
280,000
596,000
Ranking: Oregon is 13th this year; it was 8th in 2011.
Highlights:
While reon's secenrary lilesryle rare is one ol rhe lowesr in rhe
.S., rhere are srill almosr c00,000 secenrary aculrs in rhe srare.
Almosr c00,000 aculrs, or 1.7 percenr ol rhe aculr popularion,
smoke in reon.
Lasr year, 1c.8 percenr ol rhe popularion was uninsurec, rhis year ir is
14. percenr.
n rhe pasr 5 years, rhe hih school racuarion rare increasec lrom
74.2 percenr ro 7c.5 percenr ol incomin ninrh racers who racuare
in lour years.
cecreasec 20 percenr lrom 53.c ro 42. cischares per 1,000
Mecicare enrollees.
n rhe pasr 5 years, rhe inlanr morraliry rare ceclinec lrom
5. ro 5.0 cearhs per 1,000 live Lirrhs.
Health Disparities:
n reon, secenrary lilesryle is more prevalenr amon Hispanics ar
21.3 percenr rhan nonHispanic whires ar 17.3 percenr.
State Health Department Website: hrrp://puLlic.healrh.oreon.ov/
OREGON
O
R
E
G
O
N
www.americashealthrankings.org/OR
OR U.S.
9.4% 8.9%
17.5% 15.9%
$51,526 $50,054
2 012
96
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
22.4
18.3
28.6
26.2
80.5
366
4.5
9.7
17.3
12.0
10.9
$52
91.7
8.3
127.0
69.6
0.10
9.5
4.1
4.1
8.4
7.3
276.7
193.3
7,634
0.01
0.10
32
26
31
25
14
28
26
26
16
47
9
41
16
29
14
34
25
22
34
32
10
34
35
37
27
30
26
PA U.S.
7.8% 8.9%
13.9% 15.9%
$49,910 $50,054
2,236,000
2,855,000
948,000
2,615,000
Ranking: Pennsylvania is 26th this year; it was 28th in 2011.
Highlights:
More rhan 2.2 million aculrs, or 22.4 percenr ol rhe aculr
popularion, smoke in Fennsylvania.
More rhan 2.8 million aculrs are oLese in Fennsylvania, rhar is 28.c
percenr ol all aculrs.
n rhe pasr year, rhe rare ol prevenraLle hospiralizarions cecreasec
lrom 72.0 ro c.c cischares per 1,000 Mecicare enrollees.
7.5 ro .7 cases per 100,000 popularion.
Five years ao, puLlic healrh luncin was $73 per person, rhis year
ir is $52.
lrom 8.3 percenr ro 10. percenr.
Health Disparities:
n Fennsylvania, smokin is more prevalenr amon nonHispanic
Llacks ar 27.3 percenr rhan nonHispanic whires ar 18.c percenr anc
Hispanics ar 1c.1 percenr, oLesiry is more prevalenr amon non
Hispanic Llacks ar 38. percenr rhan nonHispanic whires ar 28.0
percenr, anc secenrary lilesryle is more prevalenr amon Hispanics
ar 33.c percenr rhan nonHispanic whires ar 24.5 percenr.
State Health Department Website: www.healrh.srare.pa.us

PENNSYLVANIA
P
E
N
N
S
Y
L
V
A
N
I
A
www.americashealthrankings.org/PA
2 012
97
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
20.0
19.7
25.4
26.2
75.3
257
3.9
8.0
17.5
8.4
11.8
$110
93.7
7.7
172.4
70.6
0.47
8.4
4.3
4.3
5.8
6.0
261.5
185.4
6,543
0.12
0.59
19
35
13
25
30
13
20
14
18
15
13
11
2
19
3
36
9
11
42
38
2
20
29
29
14
18
10
166,000
211,000
70,000
218,000
Ranking: Rhode Island is 10th this year; it was 13th in 2011.
Highlights:
ne in lve aculrs smoke in Fhoce slanc, rhis is
1cc,000 aculrs.
Lesiry remains Lelow rhe narional mecian ar 25.4 percenr ol
rhe aculr popularion, wirh more rhan 210,000 oLese aculrs in
rhe srare. A similar numLer ol aculrs live a secenrary lilesryle.
ceclinec lrom 20.4 percenr ro 17.5 percenr ol persons uncer
ae 18. r was 10.7 percenr 10 years ao.
Five years ao, puLlic healrh luncin was $0 per person, rhis
year ir is $110.
increasec lrom 7.3 percenr ro 11.8 percenr.
Health Disparities:
n Fhoce slanc, secenrary lilesryle is more prevalenr amon
nonHispanic Llacks ar 35.2 percenr rhan nonHispanic whires
ar 23.3 percenr, oLesiry is more prevalenr amon nonHispanic
Llacks ar 35.7 percenr rhan nonHispanic whires ar 24.7
whires ar 15.4 percenr rhan Hispanics ar 11.c percenr.
State Health Department Website: www.healrh.srare.ri.us
RHODE ISLAND
R
H
O
D
E

I
S
L
A
N
D
www.americashealthrankings.org/R
RI U.S.
11.1% 8.9%
18.6% 15.9%
$49,033 $50,054
2 012
98
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
23.1
15.4
30.8
27.2
66.0
598
5.2
11.3
26.3
10.5
19.7
$66
89.0
9.9
106.4
61.2
-0.40
12.1
4.1
4.0
12.6
7.6
276.4
191.5
9,145
-0.13
-0.54
39
8
42
39
47
46
33
35
48
38
45
31
31
47
33
24
47
49
34
29
30
40
34
34
42
42
46
SC U.S.
10.5% 8.9%
18.2% 15.9%
$40,084 $50,054
831,000
1,108,000
435,000
979,000
Ranking: South Carolina is 46th this year; it was 45th in 2011.
Highlights:
Sourh Carolina has one ol rhe hihesr rares ol ciaLeres ar
12.1 percenr ol rhe aculr popularion, wirh 435,000 aculrs wirh
ciaLeres.
n rhe pasr year, rhe hih school racuarion rare increasec lrom
c2.2 percenr ro cc.0 percenr ol incomin ninrh racers who
racuarec wirhin lour years.
increasec lrom 15.c percenr ro 2c.3 percenr ol persons uncer
ae 18.
cecreasec lrom 78.c ro c1.2 cischares per 1,000 Mecicare
enrollees.
Sourh Carolina ranks Lelow rhe mecian srare on all measures
excepr rwo Line crinkin anc prevenraLle hospiralizarions.
Health Disparities:
n Sourh Carolina, oLesiry is more prevalenr amon nonHispanic
Llacks ar 3. percenr rhan nonHispanic whires ar 27.8 percenr,
anc secenrary lilesryle is more prevalenr amon Hispanics ar 35.c
percenr rhan nonHispanic whires ar 24. percenr.
State Health Department Website: www.scchec.ner
SOUTH CAROLINA
S
O
U
T
H

C
A
R
O
L
I
N
A
www.americashealthrankings.org/SC
2 012
99
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
23.0
22.1
28.1
27.0
81.7
269
5.9
5.9
22.6
6.7
13.0
$86
87.5
6.8
109.1
63.7
0.14
9.5
3.0
3.1
29.6
7.5
236.6
171.0
6,927
-0.05
0.09
36
44
28
35
12
15
38
6
33
5
17
20
42
10
29
27
22
22
3
4
50
37
16
9
20
35
27
143,000
174,000
59,000
168,000
Ranking: South Dakota is 27th this year; it was 19th in 2011.
Highlights:
More rhan 140,000 aculrs smoke in Sourh Dakora, or 23.0 percenr ol
rhe aculr popularion.
n rhe pasr year, rhe rare ol inlecrious cisease cecreasec lrom 8.3 ro
5. cases per 100,000 popularion.
n rhe pasr lve years, immunizarion coverae croppec lrom 3.4
The rare ol prevenraLle hospiralizarions cecreasec 1c percenr lrom
7c.1 ro c3.7 cischares per 1,000 Mecicare enrollees, in rhe pasr
5 years.
n rhe pasr 10 years, rhe percenrae ol chilcren in poverry rose
sinilcanrly lrom 7.7 percenr ro 22.c percenr ol persons uncer
ae 18.
The occuparional laraliries rare cecreasec lrom .4 ro 5. cearhs per
100,000 workers in rhe pasr 5 years.
Health Disparities:
n Sourh Dakora, oLesiry is more prevalenr amon nonHispanic
Narive Americans ar 3.8 percenr rhan nonHispanic whires ar 28.3
percenr anc Hispanics ar 32.2 percenr, anc smokin is more prevalenr
amon nonHispanic Narive Americans ar 50.5 percenr rhan non
Hispanic whires ar 14.4 percenr anc Hispanics ar 17.7 percenr.
State Health Department Website: hrrp://coh.sc.ov
SOUTH DAKOTA
S
O
U
T
H
D
A
K
O
T
A
www.americashealthrankings.org/SD
SD U.S.
4.9% 8.9%
9.3% 15.9%
$47,223 $50,054
2 012
100
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
23.0
10.0
29.2
35.1
77.4
613
5.4
9.1
22.5
10.4
13.9
$83
89.5
9.0
120.4
83.4
-0.15
11.2
3.8
4.5
10.4
8.1
310.4
204.0
9,513
-0.17
-0.32
36
1
35
48
24
47
36
22
32
37
23
21
28
42
20
46
35
44
25
42
17
45
44
45
43
43
39
TN U.S.
9.2% 8.9%
15.5% 15.9%
$42,279 $50,054
1,130,000
1,434,000
550,000
1,724,000
Ranking: Tennessee is 39th this year; it was 41st in 2011.
Highlights:
n rhe pasr year, rhe percenrae ol chilcren in poverry cecreasec
Lasr year, air pollurion was 11.1 microrams ol lne parriculare
per cuLic merer, rhis year ir is 10.4 microrams, croppin c
percenr.
n rhe pasr 5 years, rhe hih school racuarion rare increasec
lrom cc.1 percenr ro 77.4 percenr ol incomin ninrh racers who
racuare in lour years.
While prevenraLle hospiralizarions remain a challene lor
Tennessee, rhe rare croppec in rhe lasr 5 years lrom 7.8 ro 83.4
cischares per 1,000 Mecicare enrollees.
lrom 10.4 percenr ro 13. percenr.
Health Disparities:
n Tennessee, oLesiry is more prevalenr amon nonHispanic
Llacks ar 42.4 percenr rhan nonHispanic whires ar 31.1 percenr
anc Hispanics ar 20.0 percenr, secenrary lilesryle is more prevalenr
amon Hispanics ar 3.c percenr rhan nonHispanic whires ar 2.5
whires ar 21.7 percenr rhan Hispanics ar 1c.4 percenr.
State Health Department Website: hrrp://healrh.srare.rn.us

TENNESSEE
T
E
N
N
E
S
S
E
E
www.americashealthrankings.org/TN
2 012
101
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
19.2
18.9
30.4
27.2
75.4
450
5.2
19.1
25.5
10.3
24.2
$57
90.1
8.4
95.0
72.3
-0.36
10.2
3.6
3.8
15.2
6.1
267.8
173.8
7,646
0.04
-0.33
14
31
40
39
28
36
33
48
47
35
50
38
27
33
43
37
45
33
15
19
39
21
30
13
28
25
40
3,593,000
5,689,000
1,909,000
5,090,000
Ranking: Texas is 40th this year; it was 42nd in 2011.
Highlights:
Almosr 5.7 million aculrs, more rhan 30 percenr, in Texas are
oLese anc more rhan 5 million aculrs, more rhan 27 percenr,
live a secenrary lilesryle.
The incicence ol inlecrious cisease remains hih, risin 4 percenr in rhe
lasr year lrom 18.4 ro 1.1 cases per 100,000 popularion.
18 percenr lrom 87.c ro 72.3 cischares per 1,000 Mecicare enrollees.
Alrhouh Texas has rhe hihesr rare ol uninsurec popularion, rhe rare
cecreasec lrom 25.0 percenr ro 24.2 percenr in rhe lasr year.
n rhe pasr 10 years, rhe rare ol low Lirrhweihr inlanrs increasec lrom
7.4 percenr ro 8.4 percenr ol live Lirrhs.
The rare ol cancer cearhs cecreasec 5 percenr in rhe pasr year, lrom
182.8 ro 173.8 cearhs per 100,000 popularion, leavin Texas wirh one
ol rhe lowesr rares ol cancer cearhs in rhe .S.
Health Disparities:
n Texas, secenrary lilesryle is more prevalenr amon Hispanics ar 33.7
percenr rhan nonHispanic whires ar 23.1 percenr, anc oLesiry is more
prevalenr amon nonHispanic Llacks ar 38.4 percenr rhan nonHispanic
whires ar 2c. percenr.
State Health Department Website: www.cshs.srare.rx.us
TEXAS
T
E
X
A
S
www.americashealthrankings.org/TX
TX U.S.
7.8% 8.9%
14.0% 15.9%
$49,047 $50,054
2 012
102
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
11.8
12.0
24.4
18.9
79.4
213
3.9
12.4
13.7
9.9
14.2
$67
88.3
7.0
89.4
36.8
0.59
6.7
3.6
3.4
19.4
5.0
211.1
128.6
6,158
0.22
0.81
1
3
6
2
19
5
20
39
8
29
24
29
37
13
45
2
6
1
15
9
46
4
4
1
6
7
7
UT U.S.
7.0% 8.9%
13.3% 15.9%
$55,493 $50,054
229,000
473,000
130,000
366,000
Ranking: Utah is 7th this year; it was 5th in 2011.
Highlights:
rah has rhe lowesr smokin rare in rhe .S. ar 11.8 percenr ol rhe
aculr popularion, however, almosr 230,000 aculr smoke.
mmunizarion coverae increasec 2 percenr in rhe pasr year, lrom
8c.c percenr ro 88.3 percenr ol chilcren aes 1 ro 35 monrhs.
cecreasec lrom 4c.8 ro 3c.8 cischares per 1,000 Mecicare
enrollees.
n rhe pasr 5 years, rhe hih school racuarion rare cecreasec
lrom 83.0 percenr ro 7.4 percenr ol incomin ninrh racers who
racuare wirhin lour years.
rah has rhe lowesr prevalence ol ciaLeres in rhe .S. ar c.7 percenr
ol aculrs, however, 130,000 aculrs have ciaLeres in rhe srare.
Health Disparities:
n rah, oLesiry is more prevalenr amon nonHispanic Narive
Americans ar 31.2 percenr anc Hispanics ar 2.4 percenr rhan non
Hispanic whires ar 23.1 percenr, secenrary lilesryle is more prevalenr
amon Hispanics ar 32.c percenr rhan nonHispanic whires ar 1c.2
percenr, anc smokin is more prevalenr amon nonHispanic Narive
Americans ar 20.3 percenr rhan nonHispanic whires ar .2 percenr
anc Hispanics ar 11.2 percenr.
State Health Department Website: www.healrh.urah.ov
UTAH
U
T
A
H
www.americashealthrankings.org/UT
2 012
103
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
19.1
18.5
25.4
21.0
89.6
130
3.9
2.8
16.4
7.0
9.0
$149
92.8
6.1
169.8
50.6
0.95
7.7
3.7
3.7
5.6
5.4
230.5
185.0
5,712
0.25
1.20
11
27
13
5
2
2
20
1
15
7
3
3
11
2
4
7
1
4
19
16
1
10
9
28
2
5
1
96,000
127,000
39,000
105,000
Ranking: Vermont is 1st this year, unchanged from 2011.
Highlights:
The prevalence ol low Lirrhweihr inlanrs cecreasec 12
percenr in rhe pasr year, lrom 7.0 percenr ro c.1 percenr ol
live Lirrhs.
increasec lrom 13.5 percenr ro 1c.4 percenr ol persons
under age 18.
vermonr has one ol rhe lowesr rares ol secenrary lilesryle in
rhe .S., however, 105,000 aculrs leac a secenrary lilesryle.
n rhe pasr 5 years, puLlic healrh luncin increasec 55
percenr lrom $c ro $14 per person.
The rare ol prevenraLle hospiralizarions ceclinec in rhe pasr
10 years, lrom cc. ro 50.c cischares per 1,000 Mecicare
enrollees.
n rhe pasr year, rhe inlanr morraliry rare increasec 12
percenr lrom 4.8 ro 5.4 cearhs per 1,000 live Lirrhs.
Health Disparities:
n vermonr, oLesiry is more prevalenr amon nonHispanic
whires ar 23.c percenr rhan Hispanics ar 1.0 percenr.
State Health Department Website: www.healrhvermonr.ov
VERMONT
V
E
R
M
O
N
T
www.americashealthrankings.org/VT
VT U.S.
5.8% 8.9%
11.6% 15.9%
$51,862 $50,054
2 012
104
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
20.9
17.9
29.2
25.1
78.4
214
3.5
8.2
14.7
9.7
13.7
$69
88.9
8.2
125.3
58.3
0.25
10.4
3.4
3.4
16.3
7.0
256.9
186.0
7,124
0.02
0.27
22
21
35
19
20
6
12
16
11
28
21
28
33
24
15
18
20
38
10
9
40
30
24
30
22
28
21
VA U.S.
6.5% 8.9%
11.8% 15.9%
$62,616 $50,054
1,305,000
1,823,000
649,000
1,567,000
Ranking: Virginia is 21st this year; it was 23rd in 2011.
Highlights:
n rhe pasr year, rhe percenrae ol chilcren in poverry increasec lrom
12.3 percenr ro 14.7 percenr ol persons uncer ae 18. r was ar 7.
percenr in 2002.
virinia has hiher rares ol oLesiry anc ciaLeres comparec ro mosr
orher srares ar 2.2 percenr anc 10.4 percenr ol rhe aculr popularion,
respecrively. There are more rhan 1.8 million oLese aculrs anc
almosr c50,000 aculrs wirh ciaLeres in rhe srare.
n rhe pasr 5 years, air pollurion cecreasec 23 percenr lrom 12.c ro
.7 microrams ol lne parriculare per cuLic merer.
The rare ol prevenraLle hospiralizarions cecreasec in rhe pasr 5
years, lrom 70.2 ro 58.3 cischares per 1,000 Mecicare enrollees.
n rhe pasr 10 years, rhe rare ol uninsurec popularion increasec 33
percenr lrom 10.3 percenr ro 13.7 percenr.
Health Disparities:
n virinia, oLesiry is more prevalenr amon nonHispanic Llacks ar
38.1 percenr rhan nonHispanic whires ar 25.1 percenr anc Hispanics
ar 24.1 percenr, smokin is more prevalenr amon Hispanics ar 27.4
percenr rhan nonHispanic Llacks ar 18.0 percenr anc nonHispanic
whires ar 17. percenr, anc secenrary lilesryle is more prevalenr
amon nonHispanic Llacks ar 30.8 percenr rhan nonHispanic whires
ar 20.7 percenr.
State Health Department Website: www.vch.srare.va.us

VIRGINIA
V
I
R
G
I
N
I
A
www.americashealthrankings.org/VA
2 012
105
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
17.5
17.8
26.5
22.0
73.7
314
3.0
10.3
18.9
9.3
14.2
$94
87.7
6.3
124.6
46.4
0.37
8.9
3.7
3.9
13.1
5.2
239.4
181.5
6,327
0.16
0.53
7
19
18
9
37
22
5
31
20
23
24
17
39
5
16
5
14
17
19
25
36
7
20
18
10
13
13
918,000
1,391,000
467,000
1,155,000
Ranking: Washington is 13th this year; it was 9th in 2011.
Highlights:
Washinron has one ol rhe lowesr smokin rares in rhe .S. ar 17.5
percenr ol rhe aculr popularion, however, more rhan 00,000 aculrs
srill smoke.
Almosr 1.4 million aculrs are oLese in Washinron, anc nearly 1.2
million live a secenrary lilesryle.
n rhe pasr year, rhe rare ol uninsurec popularion increasec lrom 13.2
percenr ro 14.2 percenr.
lrom 10.5 percenr ro 18. percenr ol persons uncer ae 18, ir was 1c.1
percenr lasr year.
The rare ol prevenraLle hospiralizarions ceclinec lrom 51. ro 4c.4
cischares per 1,000 Mecicare enrollees in rhe pasr 5 years.
Health Disparities:
n Washinron, smokin is more prevalenr amon nonHispanic Llacks
ar 20.7 percenr rhan nonHispanic whires ar 14. percenr anc Hispanics
ar 11.7 percenr, anc oLesiry is more prevalenr amon nonHispanic
Llacks ar 35.7 percenr rhan nonHispanic whires ar 2c.4 percenr.
State Health Department Website: www.coh.wa.ov
WASHINGTON
W
A
S
H
I
N
G
T
O
N
www.americashealthrankings.org/WA
WA U.S.
9.4% 8.9%
17.8% 15.9%
$56,850 $50,054
2 012
106
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
28.6
10.1
32.4
35.1
77.0
315
7.5
6.7
24.5
11.2
14.2
$129
85.5
9.2
102.5
99.1
-0.39
12.0
4.6
5.3
12.3
7.7
320.1
214.4
10,576
-0.27
-0.66
49
2
48
48
26
24
44
9
42
43
24
4
48
45
34
49
46
48
47
50
28
43
47
49
49
48
47
WV U.S.
8.1% 8.9%
13.7% 15.9%
$41,821 $50,054
421,000
476,000
176,000
516,000
Ranking: West Virginia is 47th this year; it was 43rd in 2011.
Highlights:
Lasr year, immunizarion coverae was 1.0 percenr ol chilcren
aes 1 ro 35 monrhs, rocay ir is 85.5 percenr.
Wesr virinia has rhe seconc hihesr rare ol smokin ar 28.c
percenr ol rhe aculr popularion, 421,000 aculrs smoke in rhe
state.
n rhe pasr 5 years, air pollurion cecreasec 1 percenr lrom 13.8
ro 11.2 microrams ol lne parriculare per cuLic merer.
Alrhouh rhe rare ol prevenraLle hospiralizarions remains hih,
ir croppec over rhe pasr 10 years, lrom 121.0 ro .1 cischares
per 1,000 Mecicare enrollees.
Health Disparities:
n Wesr virinia, oLesiry is more prevalenr amon nonHispanic
Llacks ar 42.0 percenr rhan nonHispanic whires ar 32.1 percenr
anc Hispanics ar 28.3 percenr, anc secenrary lilesryle is more
prevalenr amon nonHispanic Llacks ar 43.2 percenr rhan
nonHispanic whires ar 32. percenr.
State Health Department Website: www.wvchhr.or
WEST VIRGINIA
W
E
S
T

V
I
R
G
I
N
I
A
www.americashealthrankings.org/WV
2 012
107
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
20.9
24.3
27.7
22.7
90.7
249
3.3
8.0
21.4
10.0
9.9
$39
92.3
7.0
121.3
55.3
0.33
8.4
3.2
3.6
10.2
6.5
246.5
183.5
6,346
0.16
0.49
22
50
24
12
1
11
10
14
27
31
6
50
12
14
18
13
16
11
7
13
16
27
21
23
11
12
16
917,000
1,215,000
368,000
996,000
Ranking: Wisconsin is 16th this year; it was 12th in 2011.
Highlights:
Alrhouh ciaLeres remains low ar 8.4 percenr ol rhe aculr popula-
rion, rhere are almosr 370,000 aculrs wirh ciaLeres in Wisconsin.
n rhe pasr 5 years, rhe hih school racuarion rare rose lrom 85.8
percenr ro 0.7 percenr ol incomin ninrh racers who racuare
wirhin lour years.
croppec 14 percenr lrom c4.5 ro 55.3 cischares per 1,000 Meci-
care enrollees.
Health Disparities:
n Wisconsin, oLesiry is more prevalenr amon nonHispanic Llacks
ar 4.4 percenr rhan nonHispanic whires ar 27.2 percenr anc Hispan-
ics ar 1.3 percenr, smokin is more prevalenr amon Hispanics ar
2.c percenr rhan nonHispanic whires ar 17. percenr, anc secen-
rary lilesryle is more prevalenr amon nonHispanic Llacks ar 35.1
percenr rhan Hispanics ar 2c.0 percenr anc nonHispanic whires ar
21.c percenr.
State Health Department Website: www.chs.wisconsin.ov
WISCONSIN
W
I
S
C
O
N
S
I
N
www.americashealthrankings.org/WI
WI U.S.
7.8% 8.9%
14.2% 15.9%
$52,058 $50,054
2 012
108
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
23.0
18.9
25.0
25.5
75.2
196
7.2
4.1
11.7
5.1
17.5
$123
82.5
9.0
89.6
58.2
0.16
8.2
3.5
3.8
12.9
6.5
249.2
173.3
7,800
0.08
0.24
36
31
12
22
33
4
43
2
3
1
36
7
50
41
44
17
21
8
13
19
34
26
22
11
30
22
23
WY U.S.
5.9% 8.9%
10.6% 15.9%
$54,509 $50,054
100,000
108,000
36,000
110,000
Ranking: Wyoming is 23rd this year; it was 21st in 2011.
Highlights:
wirh 100,000 aculrs who smoke in Wyomin.
100,000 popularion, rhis year ir is 4.1 cases.
n rhe pasr year, immunizarion coverae cecreasec lrom 0.7
The inlanr morraliry rare ceclinec in rhe pasr year lrom 7.2 ro c.5
n rhe pasr 5 years, rhe occuparional laraliries rare cecreasec
5c percenr lrom 1c.4 ro 7.2 cearhs per 100,000 workers, ir has
ceclinec sreacily in rhe pasr c years.
ceclinec lrom 72.3 ro 58.2 cischares per 1,000 Mecicare
enrollees.
Health Disparities:
n Wyomin, oLesiry is more prevalenr amon nonHispanic Narive
Americans ar 40. percenr rhan nonHispanic whires ar 24.c percenr,
anc smokin is more prevalenr amon nonHispanic Narive
Americans ar 50.c percenr rhan nonHispanic whires ar 18.c percenr
anc Hispanics ar 24.2 percenr.
State Health Department Website: hrrp://www.healrh.wyo.ov
WYOMING
W
Y
O
M
I
N
G
www.americashealthrankings.org/WY
2 012
109
DETERMINANTS
OUTCOMES
BEHAVIORS
POLICY
CLINICAL CARE
ALL DETERMINANTS
ALL OUTCOMES
OVERALL
VALUE RANK
NO. 1
STATE
2012
SMOKING
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
OBESITY
AFFECTED 2012
Smoking
Obesity
Diabetes
Sedentary Lifestyle
STATE NATION
See Methodology for
1990 92 94 96 98 00 02 04 06 08 10 12
P
E
R
C
E
N
T

O
F

P
O
P
U
L
A
T
I
O
N
35
30
25
20
15
10
5
0
1990 92 94 96 98 00 02 04 06 08 10 12
11.8
10.0
20.7
16.5
90.7
122
2.4
2.8
8.6
5.1
4.5
$236
94.2
5.7
194.5
25.0
0.95
6.7
2.8
2.9
5.6
4.4
195.9
128.6
5,621
0.31
1.20
20.8
25.0
23.8
19.8
62.4
1330
--
27.0
34.6
10.9
10.6
--
91.4
10.2
342.9
53.4
9.1
3.6
3.4
--
10.3
306.8
201.6
10,134
Ranking: The District of Columbia is not included in the
ranking of states, as it is a unique governmental entity and is
considerably more urban than the states.
Highlights:
n rhe pasr year, rhe hih school racuarion rare increasec
lrom 5c.0 percenr ro c2.4 percenr ol incomin ninrh
graders who graduate in four years.
n rhe pasr year, rhe rare ol uninsurec popularion
cecreasec lrom 12.4 percenr ro 10.c percenr.
cecreasec lrom c5.c ro 53.4 cischares per 1,000 Mecicare
enrollees.
n rhe pasr year, rhe inlanr morraliry rare cecreasec lrom
11. ro 10.3 cearhs per 1,000 live Lirrhs, in 2007, rhe rare
was 18.7 cearhs per 1,000 live Lirrhs.
increasec lrom 31.8 percenr ro 34.c percenr ol persons
under age 18.
State Health Department Website: www.dchealth.dc.gov
DISTRICT OF COLUMBIA
D
I
S
T
R
I
C
T

O
F

C
O
L
U
M
B
I
A
www.americashealthrankings.org/DC
DC U.S.
10.4% 8.9%
15.8% 15.9%
$55,251 $50,054
INTRODUCTION
Louisiana is one of the most resilient
states in the nation, with a rich,
unique culture and history and a
dynamic populace. Unfortunately,
Louisianans have poor health overall
as evidenced by the consistently low
ranking among all states in United
Health Foundations annual Americas
Health Rankings
. We are again
at an abysmal 49th. This is consistent
with our rankings since 1990.
As public ofcials, health care
professionals, and Louisianans,
we take these rankings seriously.
Where we stand on Americas Health
Rankings matters not only for the
perception of our state, but for the
health of our 4.5 million residents
and our economic vitality. In recent
years, Louisiana has endured a
number of catastrophic events
including oods, hurricanes, oil spills,
and national economic downturn.
These events did not cause our
challenges, but rather brought them
to greater public awareness, and
also provided opportunities for us to
move forward with building a state
that is stronger, healthier, and more
resilient. Having seen our people rise following
these challenges, we are condent that Louisiana
can improve its rankings through deliberate policy
action. That is why we have set an ambitious, but
achievable, goal of reversing our rankings trend
and improving Louisianas ranking to 35th over
the next few years. This will take leadership at
the state and local levels, as well as the active
participation of every citizen. We describe herein
some actions at the state and local levels to move
towards those improved rankings.
OBESITY REDUCTION
Physical and nutritional tness is one of the
major challenges facing Louisianas population.
In 2012, 33.4 percent of our adults were
considered obese, and childhood obesity is a
serious issue. Obesity rates in our nation are high
because of a combination of changes in the built
environment and the availability of calorie-dense
foods, combined with unhealthy life choices and
insufcient policies to drive health and tness.
In June 2012, New Orleans Mayor Mitch
Landrieu unveiled a comprehensive plan to achieve
nutritional and physical tness for everyone in New
Orleans. The effort, Fit NOLA, lays out a multi-
sector strategy led by the City of New Orleans in
partnership with over 100 organizations. Through
Fit NOLA, the City of New Orleans will focus
on becoming one of the ten ttest cities in the
United States by 2018. The Fit NOLA Partnership
is a powerful step in the right direction, and it
received a $1 million grant from Blue Cross Blue
Shield of Louisiana to connect residents in three
neighborhoods with underused parks and provide
vouchers for fresh fruits and vegetables at area
farmers markets.
Last year, New Orleans was named both a
Bronze bicycle friendly community by the
League of American Bicyclists and a Bronze walk
friendly community by the Pedestrian and Bicycle
Information Center. These awards reect the City
of New Orleans commitment to making the city
more bicycle and pedestrian friendly. Recognizing
that a bike friendly city is a healthy city, since
Hurricane Katrina, New Orleans has quadrupled its
miles of bikeways.
Mayor Landrieu also spearheaded the Fresh
Food Retailer Initiative, launched in March 2011,
which will award $14 million worth of forgivable
and low-interest loans to supermarkets and grocery
stores located in underserved neighborhoods in
New Orleans. This program allows vendors to
Promoting the Publics Health in Louisiana
Commentaries
DAVID HEITMEIER, O.D.
Louisiana State Senator, Louisiana State Legislature, District 7
KAREN B. DESALV LL O, M.D., M.P.H., M.Sc.
Health Commissioner, City of New Orleans
David Heitmeier
Karen B. DeSalvo
renovate or expand retail outlets that sell fresh
fruits and vegetables in those areas of New
Orleans where access to fresh foods has been
lacking, particularly for low-income residents. In
a city that was 80 percent underwater just 7 years
ago, there are still many food deserts, and this
initiative will greatly expand access to healthier
options in our underserved areas.
At a statewide level, Louisiana Department
of Health and Hospitals (DHH), in conjunction
with Pennington Biomedical Research Center,
announced a partnership to establish best
practices that support better eating and exercise
habits for Louisianans to address obesity.
Additionally, in August 2012, DHH launched
Living Well in Louisiana, a three-month wellness
challenge designed to help Louisianans combat
obesity and its related chronic illnesses by taking
small but effective steps to eat right and exercise
daily. As part of the program, participants earn
points for physical activity and healthy eating,
compete on teams or individually, and track their
progress online.
We are also making steps in the right direction
legislatively. First passed in 2004 and updated in
2009, the Louisiana legislature enacted a law that
requires students in grades K-8 to engage in at
least 30 minutes of quality moderate to vigorous
physical activity each school day. Legislation was
also enacted that restricts the availability of full-
calorie beverages for sale to students in public
high schools, and offers healthier options like
bottled water or low or no calorie beverages.
We believe we will continue this momentum of
signicant advances in the ght against obesity
through meaningful partnerships, policies, and
programs in Louisiana.
SMOKING
Although Louisiana passed the Smoke-Free Air
Act in 2007 that prohibited smoking in most public
places, smoking in bars and casinos is still prevalent
across the state. In the absence of strong tobacco
taxation as a disincentive for smoking, and with
755,000 adults who smoke in Louisiana, we have to
be creative in our approach to smoking cessation.
Louisianas state cigarette excise tax is 36 cents per
pack of 20 cigarettes, while the national average is
$1.46 per pack of 20 cigarettes.
The Louisiana Campaign for Tobacco-Free Living
has launched an advertisement campaign, Lets
Be Totally Clear, aimed at increasing awareness
of the negative effects of secondhand smoke on
employees who work at bars or casinos. Several
bars in New Orleans
have opted to operate
smoke-free, but we have
progress to make.
Cigarette smoking
is far too common in
Louisiana, but we look
forward to continuing a
dialogue that has already
begun and taking action
to lower the number of
smokers in our state.
MATERNAL AND
CHILD HEALTH
Louisiana has the second
highest rate of low birth
weight babies (babies
born weighing less than 5.5 pounds) in the nation.
Low birthweight and prematurity contribute to
our national ranking as second highest in infant
mortality.
To address this, we are implementing new and
innovative programs to improve birth outcomes
statewide. DHH is working with its partners to help
end non-medically indicated deliveries prior to 39
weeks gestation in Louisianas birthing hospitals.
The New Orleans Health Department is working
through Healthy Start New Orleans and with LSU
Health Sciences Center and the State of Louisiana
to implement the Best Babies Zone Project and the
Inter-Pregnancy Care Project, programs that reect
our commitment to working with mothers and
families to improve birth outcomes.
These programs have similar goals: to create
systems change with the goal of reducing infant
mortality and improving birth outcomes. We are
hopeful that these programs will have a positive
impact on our tragic infant mortality rate.
We believe we
will continue this
momentum of
signicant advances
in the ght against
obesity through
meaningful
partnerships, policies,
and programs in
Louisiana.
DIABETES
One in 10 Louisianans suffers from diabetes.
This is above the national median, which is 8.7
percent. Recognizing that type II diabetes can
be prevented by monitoring exercise, blood
pressure, cholesterol and diet, we have taken some
innovative approaches to combating diabetes in
New Orleans.
In April 2010, the U.S. Department of Health
and Human Services, Ofce of the National
Coordinator for Health Information Technology,
chose the Greater New Orleans area as one of
17 Beacon Communities in the country. The goal
of the Beacon program is to demonstrate and
accelerate the role of information technology
in population health improvement across the
continuum of care. All
major hospital systems
and community-based
primary care providers
are participating in this
community collaborative,
which is coordinated by
the Louisiana Public Health
Institute. The project
focuses on chronic disease,
mainly diabetes and
cardiovascular disease, by
accomplishing the following:
1) Improving quality of
care at the population
level in measurable ways;
2) Implementing health
information technology
(HIT) as an enabler for
efciency and scalability;
3) Developing community-level, chronic disease
standards of care; and 4) Implementing sustainable
quality improvement efforts.
Through the use of innovative programs such as
Txt4Health, the Beacon project has leveraged
the power of mobile technology to allow New
Orleanians to feel empowered to take action with
their health. Txt4Health is a 14-week text-based
program that encourages participants to engage
with and manage their health, helps assess risk for
type II diabetes, sets goals for increased activity
and weight loss, and links individuals with local
providers who may be able to provide care if
necessary.
PRIMARY CARE
One area in which we are doing well as a state is in
primary care. Seven years after Hurricane Katrina,
the primary care infrastructure in Louisiana has
grown. The greater New Orleans area has 102
service sites for uninsured, under-insured, and low-
income residents. These sites include mobile units,
school-based health clinics, residency training sites,
and those who serve special populations such as
HIV-positive and homeless patients, representing a
heterogeneous mix of providers delivering care to
the highest need populations in innovative ways.
In the 2011 rankings, Louisiana ranked 23rd in
the nation with 117.9 primary care physicians per
100,000 population. This area of success is the
result of deliberate planning and policymaking to
ensure that our workforce and access to healthcare
remained strong after Hurricane Katrina.
CONCLUSION
We recognize the signicant impact that social
determinants like poverty and education play on
the health of Louisianans, and we are working
to ensure that we improve these factors which
contribute to the publics health. On these
and other public health initiatives, we remain
committed to protecting and promoting the health
of New Orleanians and all Louisianans so that we
may more effectively tackle our communitys public
health challenges. We are optimistic that we can
achieve our goal to reach 35th in the nation. We
can and must do better as a state. Louisianans
deserve no less.
Dr. DeSalvo is the Health Commissioner and Senior
Health Policy Advisor to Mayor Mitch Landrieu
for the City of New Orleans. Senator Heitmeier
represents Louisiana State Senate District 7 and is
Chairman of the Louisiana State Senate Health and
Welfare Committee.
Through the use of
innovative programs
such as Txt4Health,
the Beacon project
has leveraged the
power of mobile
technology to allow
New Orleanians to
feel empowered to
take action with
their health.
Commentaries
For over 20 years, Americas Health Rankings
has
been a reliable source of comparative information
on health determinants and outcomes across the
United States. This report is taken seriously as
an important assessment of a states current and
future health. Throughout the years, state health
ofcials have been summoned by their governors
and delivered an ultimatum: Fix the health
rankings. Americas Health Rankings
is
an effective call to action. In this commentary,
I present promising strategies to improve the
health of the nations residents as documented
in this report.
IMPROVING HEALTH
Improving health outcomes requires an all hands
approach. Leadership and grassroots efforts
are required across a range of parties including
government, community groups, and private
businesses. State and territorial health ofcials are
uniquely positioned to drive health improvement.
As part of the Association of State and Territorial
Health Ofcials (ASTHO) orientation, new
state and territorial health ofcials learn about
. We discuss the key

health determinants and outcomes highlighted
in the report, noting which areas show success
for the state and which present challenges, and
we highlight racial disparities. Unfortunately,
improvement as measured by the rankings has
slowed over the decade. The 2011 Edition of
the rankings showed that while overall health
improved 21 percent since the rst edition of the
report, it improved at a rate of 1.6 percent in the
1990s and only 0.5 percent in the 2000s. Sadly,
measures of health disparities have not improved.
We cannot let improvement slow to a halt; we
must all redouble our efforts. As we face ongoing
economic challenges and diminishing resources,
we must be as efcient and effective as possible.
We can use the rankings to identify opportunities
and set clear improvement goals. We must
Improving Health Outcomes:
the Role of State Health Leadership
PAUL E. JARRIS, M.D., M.B.A.
Executive Director
Association of State and Territorial Health Ofcials
embed the science of continuous
quality improvement (CQI) in
the leadership and management
of our programs and services.
We can then drive improvement
using strategies supported by
the evidence base. The CDCs
Guide to Community Preventive
Services and its companion,
the Guide to Clinical Preventive
Services, provide many proven
options for addressing some of
the most pressing health problems. Oftentimes,
however, we need to tackle new threats, address
old threats in a new context, or do something
better than it has ever been done before. In these
situations the current evidence base is insufcient.
We must innovate to expand the evidence base,
work to advance implementation science, and
bring interventions to scale. Even when a strong
evidence base exists, adaptation and adjustments
are necessary for efforts to succeed in a specic
environment.
Improvement will accelerate if we rely on the
evidence when we have it, innovate when we
dont, and share lessons learned within the eld.
Whether by engaging in learning collaboratives,
submitting a promising practice to be compiled
by organizations such as the United Health
Foundation, ASTHO, American Public Health
Association (APHA) or National Association of
County and City Health Ofcials (NACCHO), or
participating in a research study, we must give
others the benet of our learning. The more
information we can add to the evidence base
about what works and under what circumstances,
the more effectively we can improve health. State
health agency leaders are uniquely positioned to
collaborate with our academic partners and drive
practice-based public health services and systems
research (PHSSR) that will increase our collective
effectiveness in years to come.
Commentaries
Leaders must
utilize the
best available
data and
information at
the state and
local levels.
SETTING IMPROVEMENT GOALS
provides an
excellent stimulus and key data for setting
health improvement goals. The World Health
Organization (WHO) describes the objective of
good health as twofold, including goodness,
the best attainable average level of health, and
fairness, the smallest feasible differences among
individuals and groups. ASTHO denes health
equity as the attainment of the highest level
of health for all people. Achieving health equity
requires valuing everyone equally with focused
and ongoing societal efforts to address avoidable
inequalities, historical and contemporary injustices,
and the elimination of health and healthcare
disparities. Health inequities exist among
groups based on gender, sexual orientation, race,
ethnicity, education, income,
disability, and geographic
location. In addition, the burden
of health inequities constitutes
a huge nancial and social cost
to our nation. We simply cannot
become a healthy nation if we do
not rigorously and deliberately
take action to improve and
achieve health equity. As we
establish improvement goals for
our work it is imperative that
we create both goodness and
fairness goals. In this manner
we will improve overall health
and close the gaps between our
people and communities. State
and territorial health ofcials
have committed to Strengthen the effectiveness,
value, and relevance of state and territorial public
health in promoting health equity and improving
health outcomes.
At a federal level this attention to fairness
is demonstrated in our nations rst National
Stakeholder Strategy to Achieve Health Equity, as
an overarching goal of Healthy People 2020, and
as part of the National Prevention Strategy. We
call upon all those engaged in improving health
to specically examine their contributions and
establish explicit goals to achieve health equity.
DRIVING IMPROVEMENT
There are many variations on the metaphor
you dont fatten a calf by weighing it and this
is equally true of measurements of the publics
health. Measurement is a rst and critical step.
Deliberate and strategic action to transform
the rich information contained in this report
is an essential next step. Sustainable scalable
improvements require a systematic approach.
This report focuses on both the determinants of
health, which drive future health outcomes, and
the health outcomes themselves, which reect
the current state of health. Multiple interventions
are necessary to change a complex system. The
socio-ecological model provides a frame for both
upstream and downstream interventions that can
work across health agencies and multiple partners
in public health, health care, and the community.
Expertise is needed at the individual level to
promote self-efcacy, at the interpersonal level
to affect social norms and supports, and likewise
at the organizational, community, and policy
levels. Rapid cycle improvement processes require
timely data to drive decision making and course
correction. Leaders must utilize the best available
data and information at the state and local levels.
National data, while allowing comparisons between
jurisdictions, is often lagged by several years, which
makes it less useful to guide real-time improvement
efforts. The Georgia Department of Public Health
developed an innovative approach to combating
infant mortality, beginning with geo-location.
Epidemiologists plotted vital statistics and census
information, among other data sets, to identify
clusters of increased infant mortality in a shnet
consisting of squares with 1x1 mile cell sizes which
now allows the department to direct interventions
in specic target locations and to maximize limited
resources. In one of six identied clusters, a special
response program called Baby Luv is instrumental in
reducing the infant mortality rate from 16.7 percent
to 6.9 percent in the intervention population.
Further interventions are planned.
Partnership and collaboration are essential.
No one group has all the expertise and inuence
required to create sustainable systematic
improvements. Broad-based public and private
collaborations bring together the passions,
distinctive competencies, and unique contributions
of multiple parties and opinion leaders.
Engagement of community members can
assure the effort is consistent with community
priorities and is culturally sensitive. This level
of collaboration requires a neutral convener,
which is a role public health agencies can play
very effectively. State health agencies, working
with their local counterparts, can convene
nonthreatening meetings of multiple parties,
including cabinet agencies and legislators,
advocacy groups, competing healthcare entities
including health systems and insurers, private
sector groups such as employers, and community
and faith groups. Furthermore, unlike many
groups, public health agencies have no direct
nancial stake in the health sector. The job of
convening and organizing a highly functioning
collaboration takes much work and is critical to
enable the mission-oriented efforts to succeed.
Without an effective party in the role of convener,
centrifugal force will spin off many important
partners.
An example of this type of a systematic
approach to improve prematurity can be found at
http://www.astho.org/healthybabies/. Forty-eight
states have signed pledges to reduce preterm
births by 8 percent by 2014. The strategy involves
broad-based stakeholder teams led by the state
health ofcial and organizes around the socio-
ecological model. Dramatic results are occurring.
Oklahomas Every Week Counts initiative has
reduced elective pre-term births by over 66
percent, decreased NICU admissions, and
lowered costs.
LEADING CHANGE
Effective leadership is another critical element for
driving improvement. In tough economic times,
erce competition exists for scarce human and
nancial resources. The more innovative and
promising an idea is, the more it may threaten
others who are also vying for limited attention and
funds. Thus buy-in from high-level leadership is
essential. A governor, state health ofcial, county
commissioner, mayor, business, nonprot, or faith
leader may use their bully pulpit and credibility
to champion the cause of improvement and hold
the participants accountable for working together.
Leaders can hold parties accountable, access the
media, and rally the grassroots efforts to create a
movement.
This reports focus on both the determinants of
health and health outcomes makes it a uniquely
valuable resource to help health leaders engage
their counterparts in other sectors in the discussion
about improving the health of the population.
Health leaders can use Americas Health Rankings
to start a conversation with education ofcials

about graduation rates and their impact on
health, or with public safety ofcials about violent
crime, or transportation ofcials about community
walkability, or agriculture ofcials about access to
healthy affordable foods. This kind of cross-cabinet
and cross-sectoral leadership is an imperative for
the health in all policies approach required to
tackle the health challenges we face today.
Innovative public health leaders will also
leverage the assets and reach of private sector
partners to improve the health statistics contained
in this report. Private sector employers are
increasingly seeing the value of worksite wellness
programs to increase employee morale, decrease
health care costs, and increase overall productivity.
Public health ofcials are becoming increasingly
engaged with hospitals and health systems as they
develop community health needs assessments. The
Internal Revenue Service (IRS) requires that non-
prot hospitals develop community health needs
assessments, and the Public Health Accreditation
Board requires that health departments complete
health assessments before even applying for
accreditation. Americas Health Rankings
is
an excellent place to start when considering
important health determinants and outcomes and
their trends over time.
It is up to each of us who read and study
this report to take the next step and activate
our sphere of inuence. ASTHO is committed
to learning how the states that have made
signicant improvements in the Americas Health
Rankings
have done so and convening a learning

collaborative led by state health ofcials to
accelerate improvements in health equity and
health outcomes of our nation. The well-being and
economic vitality of America depend upon it.
The latest edition of Americas
Health Rankings
, published
annually by the United Health
Foundation, the American
Public Health Association and
the Partnership for Prevention,
identies the gaps in health and
health care in the United States.
Despite the fact that the United
States is home to world class
medical centers that provide
state of the art medical care,
Americas health continues to
decline in a number of areas.
Why is this and what must we
do as a society to begin seeing
improvements at all levels of
care? Obesity and its associated
health conditions, such as
diabetes, continue to rise. Tobacco use had been
in decline but the past year saw no change in some
age groups and slight increases among young
adults. Chronic diseases resulting from not only
tobacco use, but also alcohol misuse, unhealthy
diets and physical inactivity mete tremendous
health, economic and social consequences. As we
enter a changing health care system due to federal
health care reform, we have the opportunity to
create and implement innovative, crosscutting
interventions in health promotion and disease
prevention. Bridging the health gaps across the
diverse populations in the United States requires a
multi-prong approach from a wide range of public
and private sectors.
At the American Medical Association (AMA),
we capitalize on the inuential role of physicians
and other health care providers in addressing
key determinants of health in clinical practice
and at the community level. The AMA works with
individual physicians and organizations on issues
that intersect science, medicine and public health
to improve the nations health with evidence-based
approaches to prevention and treatment. The
evidence is clear that preventing chronic diseases
or minimizing their severity will not only improve
health and disease outcomes, but improve quality
of life for patients and their families. According to
the Centers for Disease Control and Prevention,
7 out of 10 deaths among Americans each year
are from chronic diseases, and an estimated 1
out of every 2 adults suffer from at least one
chronic illness.
1
About one quarter of people with
chronic conditions have one or more daily activity
limitations; diabetes in particular continues to be
the leading cause of kidney failure, non-traumatic
lower-extremity amputations, and blindness among
adults. The four most common causes of chronic
diseases are modiable behaviors: lack of physical
activity; poor nutrition; tobacco use; and excessive
alcohol consumption. In fact, excessive alcohol
consumption is the third leading preventable cause
of death in the United States, behind diet/physical
activity and tobacco.
There is growing evidence that interventions to
increase physical activity, improve eating habits,
decrease tobacco use and exposure, decrease
risky and harmful alcohol use, and adopt positive
mental strategies will reduce the burden of
disease, disability and premature death. For
example, research in middle-aged adults (aged
45-64) who had recently adopted a healthy lifestyle
(as measured by 5 or more fruits and vegetables
Americas Declining Health
is Opportunity for Medical and
Community Partnerships
JEREMY A. LAZARUS, M.D.
American Medical Association
Commentaries
per day, regular physical activity, not smoking, and
having a BMI less than 30) found a 40% decrease
in all-cause mortality and a 35% decrease in
cardiovascular disease events over four years.
2
There is also research showing that these changes
will lead to a more productive workforce and
reduced health care costs.
3-5
In addition, there is evidence that greater use of
high-value preventive services, particularly smoking
cessation advice and assistance, and alcohol
screening and brief counseling, will save lives, with
little additional investment.
6
The United States Preventive Services Task Force
recommends varying levels of health behavior
screening and counseling by clinicians to prevent
and manage chronic diseases in their patients.
7-9
In order to support physician efforts to implement
health behavior screening and counseling, the
AMA created the AMA Healthier Life Steps
Program
. It consists of user-friendly tools that

clinicians can easily use to engage and empower
patients in four key health behaviors: healthy
eating, physical activity, reducing risky drinking,
and eliminating tobacco use. AMA Healthier
Life Steps
is designed to be used even in the

most time- and nancially- restricted health care
settings. Tools such as these are instrumental in
creating partnerships between patients and health
care providers that will improve disease outcomes
and overall health. Physician interventions that
address these four key health behaviors are some
of the most effective interventions for improving
patients health outcomes.
10
Every individual can benet from improving his
or her lifestyle behaviors. The AMAs Healthier Life
Steps
key health behaviors are the foundation of

good health and longevity, but are also pivotal in
managing chronic diseases like diabetes and heart
disease, which are crippling our nation. Physicians
and other health care providers can address the
key health behaviors without hesitancy with the
program by:
Asklng paflenfs fo complefe a brlel sell-
assessment at check-in, which communicates
the importance of the four key health behaviors
to patients.
Recordlng vlfal slgns and BMl on a paflenf
action plan summary.
Dlscusslng fhe lour
health behaviors
during the exam
and/or consult
based on a patients
readiness.
Encouraglng paflenfs
to develop action
plans by completing
an action plan
summary for every
patient to take
home, including a
brief description of
the patients health
behavior goals.
Charflng and
following up with the
patient at the next visit.
Commlfflng fo fhe program.
Relerrlng paflenfs fo communlfy resources.
Collaboraflve declslon-maklng and brlel, mulfl-
behavioral interventions are effective in helping
motivate and engage patients in maintaining or
adopting healthy lifestyles. However, medical
groups cannot be given the sole responsibility
for promoting and supporting healthy lifestyle
behaviors. There is a growing recognition and
understanding of the role that community
networks, physical and social environments, and
The four most
common causes of
chronic diseases
are modiable
behaviors: lack of
physical activity; poor
nutrition; tobacco
use; and excessive
alcohol consumption.
public policy all play in fostering healthy lifestyles.
A broad approach is necessary to achieve and
support healthy lifestyles in individuals. It requires
individual commitment, health care system
redesign, as well as community, employer and
payer support.
To that end, the AMA is working to help
physicians and other health care providers connect
their patients to community resources that can help
patients follow through on their clinicians advice to
improve their health behaviors.
The AMAs Community Health Leadership
program provides information and resources to
help improve physicians connections with public
health and private programs in the community
that will best support patients. Part of AMAs
Healthier Life Steps
, the AMAs Community

Health Leadership program also trains physicians
to promote community policies that support their
patients efforts to engage in healthier lifestyle
behaviors.
provide valuable
insights into the clinical and public health
successes of our health care system, and identies
those areas where more concerted efforts are
needed. The AMA is committed to continually
improving clinical and public health efforts to
improve the health of all Americans.
Commentaries
References
1. Centers for Disease Control and Prevention (CDC). Chronic
disease and health promotion. http://www.cdc.gov/chronicdisease/
overview/index.htm Updated August 13, 2012. Accessed Septem-
ber 3, 2012.
2. King DE, Mainous III AG, Geesey ME. Turning back the clock:
adopting a healthy lifestyle in middle age. Am J Med 2007;120:598- d
603.
3. Ozminkowski RJ, Ling D, Goetzel RZ, et al. Long-term impact of
Johnson & Johnsons health and wellness program on health care
utilization and expenditures. J Occup Environ Med 2002;44:21-29.
4. Ozminkowski RJ, Goetzel RZ, Smith MW, et al. The impact of the
Citibank, NA, health management program on changes in employ-
ee health risks over time. J Occup Environ Med 2000;42:502-11.
5. Goetzel RZ, Anderson DR, Whitmer RW, et al. The relationship
between modiable health risks and health care expenditures: an
analysis of the multi-employer HERO health risk and cost database.
J Occup & Environ Med 1998;40:843-54.
6. Maciosek MV, Cofeld AB, Flottemesch TJ, et al. Greater use of
preventive services in the U.S. health care system could save lives
at little or no cost. Health Affairs 2010;29:1656-60.
7. US Preventive Services Task Force (USPSTF). Counseling to
prevent tobacco use and tobacco-caused disease in adults and
pregnant women: clinical summary of U.S. Preventive Services
Task Force recommendation. April 2009. Rockville, MD: Agency
for Healthcare Research and Quality Website. Available at: http://
www.uspreventiveservicestaskforce.org/uspstf09/tobacco/tobac-
cosum2.htm Accessed July 19, 2012.
8. US Preventive Services Task Force (USPSTF). Screening and
behavioral counseling interventions in primary care to reduce
alcohol misuse: recommendation statement. http://www.uspreven-
tiveservicestaskforce.org/3rduspstf/alcohol/alcomisrs.htm#clinical.
Accessed July 31, 2012.
9. Moyer V. on behalf of the U.S. Preventive Services Task Force.
Behavioral Counseling Interventions to Promote a Healthful Diet
and Physical Activity for Cardiovascular Disease Prevention in
Adults: U.S. Preventive Services Task Force Recommendation
Statement. Ann Intern Med. 26 June 2012. [Epub ahead of print].
http://annals.org/article.aspx?articleid=1200998. Accessed July
31, 2012.
10. Jepson, RG, Harris FM, Platt S, Tannahill C. The effectiveness of
interventions to change six health behaviors: a review of reviews.
BMC Public Health. 2010; 10:538. doi: 10.1186/1471-2458-10-538
When I came to the conclusion that we have an
obesity epidemic in this country I wanted to do
something about it. Primarily to combat this grow-
ing problem in our country, I agreed to serve for
the last four years as the only non-physician on
the Board of Trustees for the American Medical
Association (AMA). The AMA is the largest physi-
cian organization in the country, and is dedicated
to promoting better public health.
I also serve as the Chief Operating Ofcer of The
Trust for Public Land, the nations largest organi-
zation committed to ensuring that everyone, in
particular every child, enjoys close-to-home access
to a park, playground, garden or natural area. That
is the mission of our Parks for People initiative.
Since our founding 40 years ago, The Trust for
Public Land has acquired over 3.1 million acres of
land, through 5,295 park and conservation projects
across 47 states. That land has later been trans-
ferred to local, state and federal governments to
create new parks and expand existing parks. Since
1996, we have also led a variety of voter-inspired
bond initiatives, which have resulted in over $34
billion in additional funds dedicated for the
creation of more parks.
What I have learned from my service with the
AMA regarding obesity:
1. The obesity problem in this country is un-
acceptable and getting worse. Currently, 35.7%
of our population is obese, a condition which
increases the risk of heart attacks, strokes, diabetes
and several forms of cancer and arthritis. If cur-
rent trends continue, one study projects that half
of Americans will be obese by 2030, and obesity
related diseases could increase ten-fold between
2010 and 2020, and then double again by 2030
(Healthy Americans [HA], 2012).
2. Not only does obesity cost us lost years of our
lives and lost enjoyment during those shortened
lifetimes, it costs us a great deal of money. In
2008, we spent $147 billion on health care related
to obesity (CDC, 2012), and those costs are pro-
jected to increase to $344 billion annually within
Take It Outside:
the Health Benets of Parks
10 years (Hellmich, 2009). Beyond the
direct costs, there is an even more sig-
nicant economic loss, a loss that can
be measured in terms of absenteeism,
lack of productivity, and related factors.
Economic productivity losses are esti-
mated to be between $390 billion and
$580 billion by 2013 (Voelker, 2012).
3. A healthy diet can help, but exer-
cise is also very important. Yet people
are not exercising. Almost half (49%) of
Americans get less than the minimum
recommended amount of physical ac-
tivity, and 36% of adults engage in no
exercise at all (Harnik, 2011).
4. We know exercise can make a
difference. A recent study found that
children who exercised 20 minutes a
day lowered an important measure of
diabetes risk by 18%, and exercising 40
minutes a day reduced the risk by 22%
(Davis, 2012). Researchers also empha-
sized that exercise should be fun to
keep children engaged in this benecial behavior.
The AMA has taken a number of steps to educate
Americans regarding a variety of successful changes
to our diet and lifestyle, based on various studies
and programs conducted across the country. To that
end, the entire September 2012 issue of the Journal
of the American Medical Association was devoted
to obesity. The AMA is also helping doctors nd
ways to discuss obesity with patients in a non-threat-
ening and life-changing fashion in its new program,
Weigh What Matters.
I dont want to see my friends and fellow Ameri-
cans eat ourselves to death, or live with the diseases
and soaring medical costs related to obesity. Be-
cause one way to ght obesity is with more exercise,
I searched for a national organization committed to
creating more places where people could get out-
doors and get the physical activity they need.
That organization is The Trust for Public Land, and
we are taking several steps to help ght obesity:
CHRIS KAY
Chief Operating Ofcer
The Trust for Public Land
Commentaries
This program
makes it easier and
more enjoyable
for children to be
active and play, and
also to develop
good habits which
can last a lifetime.
1. We make people aware of how they can use
existing parks, help develop new parks and trails,
enhance existing parks, and make it easier and
more enjoyable to live healthier lifestyles. We have
ofces in 34 cities, and we have tailored a number
of programs and projects to meet the specic
needs and desires of the communities we serve.
2. We have made it a priority for people to know
what parks are in their neighborhood, and how
their city ranks in providing and maintaining its
system of parks. In May, 2012, we launched The
Trust for Public Land ParkScore
, the most com-

prehensive analysis ever done of the park systems
in the 40 largest cities in the
U.S. One key component of our
grading system was calculating
how much of a citys population
lives within a 10-minute walk
of a park. Since our report was
published, a number of city
ofcials have adopted our
goals of creating more parks
and open space, and they are
using the 10-minute walk stan-
dard. One city, which had not
scored well, immediately initi-
ated a bond measure to create
more funds for new parks. The
bond measure received a 58% passage rate less
than six months later.
3. We are working together with city and county
governments, national and regional health care
organizations, major corporations and foundations
to install sturdy, state-of-the-art outdoor exercise
equipment in existing parks. Our Trust for Public
Land Fitness Zone
Program began in Los Angeles,

where we now have 41 such tness zones, and it
has spread to many other cities across the country.
Our adult equipment is installed in areas adja-
cent to childrens playground equipment, so that
parents can exercise while watching their children
play and children learn the importance of exercise
from their best role models their parents. We
have also installed equipment for younger children,
yet another way we are addressing the growing
problem of childhood obesity. Our goal is to make
exercise fun and accessible for everyone.
4. We renovate old schoolyards and transform
them into multipurpose playgrounds, creating fun
new play areas for the students while school is in
session, as well as much needed neighborhood
playgrounds when school is out. We have designed
more than 175 such schoolyards in New York (and
built the playgrounds in 54 schools to date), and
we are now doing the same in other cities. This
program, which also employs The Trust for Public
Lands Green Infrastructure design and building
disciplines, makes it easier and more enjoyable for
children to be active and play, and also to develop
good habits which can last a lifetimeall in the
ght against childhood obesity. (An additional ben-
et of this program is helping cities increase their
growing stormwater management challenges.)
5. We are turning abandoned or seldom-used
urban railroad lines into neighborhood parks (Rails
to Trails Program). For example, we have been
retained by the Chicago Park District to be the
private sector leader of a public-private effort to
convert a 2.7 mile long rail line into the worlds third
elevated, linear park. Known as the Bloomingdale
Trail, the project costs more than $90 million and
will provide a new park for walking, hiking, cycling
and other forms of healthy activity to the 36,000
households adjacent to the Bloomingdale Trail. In
addition, through connections to Chicagos existing
network of parks and trails, the Bloomingdale Trail
will serve hundreds of thousands more residents,
businesses and visitors. In addition to the 15 acres
of new elevated park space, we are building six
new street-level parks which provide access to the
trail throughout the various neighborhoods where
the line runs. We are pursuing similar efforts in cities
from New York to Seattle, all with the mission to
create parks that are more accessible and more
enjoyable for more people.
What does this mean to you? What action should
you take?
1. It starts with you promise yourself you will
take better care of yourself. If you wont do it for
yourself, then do it for family and friends, those
people who need you and count on you. I appreci-
ate the message of Dr. Reed Tucksons book, The
Doctor in the Mirror. We need to take responsibility
for our own health. It will take time and personal
commitment. It may not come quickly. But living a
longer, healthier and happier life is certainly worth
it, for both you and your family. For more informa-
tion about the effects of obesity on you and your
loved ones, and how you can lead a healthier
life for many years to come, I encourage you to
visit the AMAs website (www.ama-assn.org),
and to also ask your doctor for advice and
encouragement.
2. Get movingit can be fun. Start with a daily
10-minute walk around your neighborhood. Even
better, take a daily (or frequent) walk to a near-
by park. Parks are the most unique and enjoy-
able public places. In a park, you can spend time
with your family and friends, engage in physical
activity, or just appreciate the stunning beauty of
nature and the quiet contemplation of a solitary
walk amongst the trees. If you dont know where
the closest park is to your home, visit our website
(parkscore.tpl.org) for parks in the 40 largest cities
in the country, or contact the Parks Department in
your city.
3. Pass what you experience on to others. At
home, at work, among your friends, or where you
worship, you can reach out to others and encour-
age them to live a more active lifestyle. It is a
lot easier, and often more enjoyable, if you and
another person support each other in this life-
extending process. Make it a life-changing habit
together.
4. Join us in our mission to create more parks
and enhance existing parks. In all our efforts,
we work with the people in the communities we
serve: mayors and other elected ofcials, corpora-
tions, foundations, civic leaders, local organiza-
tions, and individualspeople like you. Commu-
nity engagement is a focal point and strength of
all our urban programs. Together, we can make
your community a better place to live a long and
healthy life. Visit our website (tpl.org) for a list of
all the parks we have created or enhanced across
the country, and learn about the work we are
doing in your city.
And if you lead an organization, contact me
directly at chris.kay@tpl.org. As the former Chief
Operating Ofcer of a Fortune 200 company, I
know how vital it is to improve the health and
welfare of our companys employees, our custom-
ers, the communities where we work and live, and
at the same time meet all our business objec-
tives for our shareholders. At The Trust for Public
Land, we have helped a variety of businesses and
organizations accomplish all these laudable objec-
tives, and we welcome the opportunity to discuss
similar win-win proposals with you. As the study
in the recent Journal of the American Medical As-
sociation demonstrated, even 20 minutes of daily
exercise can make a huge difference in the health
of a child.
Why do we at the AMA and The Trust for Public
Land ght this battle? Its simple people will live
longer, healthier and happier lives as we reduce
the amount of obesity in this country, and our
nation will save billions of dollars. Why should you
join us? Because you also want to live longer, be
healthier, and enjoy life both the life you live,
and the lives of your children, your family, and
friends.
Albert Einstein once said, Look deep into na-
ture, whether close or far away, and then you will
understand everything better. And teach others
to do the same. These were words of uncommon
wisdom from a wise man at that time, and they are
even more applicable today. Join us in building
new parks, improving those which already exist,
and in helping Americans learn the joys and ben-
ets of parks and the outdoors for this genera-
tion and for many more generations to follow.
References:
Healthy Americans (2012). F as in Fat: How Obesity Threatens
Americas Future 2012. Retrieved October 15, 2012, from http://
healthyamericans.org/report/100.
Center for Disease Control and Prevention (2012). Adult Obesity
Facts. Retrieved October 15, 2012, from http://www.cdc.gov/
obesity/data/adult.html.
Hellmich, N. (2009). Rising Obesity Will Cost U.S. Health Care $344
Billion A Year. USA Today. Retrieved October 15, 2012, from
http://usatoday30.usatoday.com/news/health/weightloss/2009-
11-17-future-obesity-costs_N.htm.
Voelker, R. (2012). Escalating Obesity Rates Pose Health, Budget
Threats. Journal of the American Medical Association, 308(15),
1514.
Harnik, P. (2011). From Fitness Zones to the Medical Mile: How
Urban Park Systems Can Best Promote Health and Wellness. The
Trust for Public Land.
Davis, C. (2012). Exercise Dose and Diabetes Risk in Overweight
and Obese Children. Journal of the American Medical Association,
308(11), 1103-1112.
Commentaries
Partnership for Prevention is pleased
to support the United Health Founda-
tion as it releases the 2012 Edition of
. By high-
lighting health and the many factors
that affect it, the rankings recognize
healthy states, identify opportunities
for improvement, and provide infor-
mation that states, communities, and
individuals can use in their efforts to
improve health.
The Rankings also highlight the
importance of prevention.
To rank states, Americas Health
Rankings
assigns a composite score

to states that accounts for health be-
haviors, community and environmental
factors, health policies, clinical care, and health
outcomes. Prevention is at the heart of each of
these areas.
Specic measures of health behavior include:
smoking, obesity, binge drinking, and sedentary
lifestyle. Community and environmental measures
include: violent crime, occupational fatalities,
infectious disease, children in poverty, and air
pollution. Health policy and clinical care measures
include: lack of health insurance, public health
funding, immunization coverage, early prenatal
care, primary care physicians, and preventable
hospitalizations. And nally, health outcome
measures include: poor mental health days, poor
physical health days, geographic disparity, infant
mortality, cardiovascular deaths, cancer deaths,
premature deaths, and diabetes.
The whole list shouts, Prevention! Prevention!
Prevention!
And thats good news because prevention is
generally better than treatment, and there exists
a plethora of evidence-based preventive mea-
sures that positively inuence health determinants
and health outcomes. A few examples include:
The Answer is Prevention
EDUARDO SANCHEZ, M.D., M.P.H., F.A.A.F.P.
Chairman
Partnership for Prevention
increasing screening and counseling in physician
ofces to reduce smoking, building more parks
and playgrounds to promote physical activity,
and using disease management to improve
diabetes care.
The possibilities are nearly endless, and the
timing couldnt be better. If, as a nation, we hope
to achieve better quality health services, better
health, and lower costs, it is imperative that we
embrace health promotion and disease prevention
policies and programs as key strategies and tactics.
Health insurance coverage is made more acces-
sible under the Patient Protection Affordable Care
Act, funding is made available for communities
through the Prevention and Public Health Fund,
and technical resources are growing to help deci-
sionmakers choose clinical and community preven-
tive services that are known to work and make
sense for patients and communities.
Partnership for Preventions National Commis-
sion on Prevention Priorities (NCPP) has ranked
recommended clinical preventive services based
on their health impact and cost effectiveness and is
developing a decision support tool for community
preventive services. The U.S. Preventive Services
Task Force and the Task Force on Community Pre-
ventive Services have recommended clinical ser-
vices and community activities based on evidence
of effectiveness. A new online database (What
Works for Health), launched by the County Health
Rankings project, catalogs policies and programs
that communities can implement. And public
health accreditation is becoming a reality that will
assure quality and help health departments target
limited resources for improving health.
helps states see

where they stand, both in terms of overall health
and in specic areas such as smoking, obesity, and
diabetes. Theres great potential for states and
communities to improve health, especially if they
focus on prevention.
At a time when our nations health system is being
transformed putting more of an emphasis on
preventing disease, ensuring wellness and provid-
ing insurance coverage to more people to increase
access to care we have a unique opportunity.
We can not only help those people who are
walking in the doors of our health care providers
ofces with a medical concern. But we can also
reach people before they become patients through
policy and environmental change that improves
health and wellness across the community. The
2012 Americas Health Rankings
report helps us
identify opportunities for improvement that, if
used effectively, can benet both individual and
population health. This means more people can
benet from systems of care, and more people can
live healthier, productive lives.
As health coverage expands, the opportunity to
improve health also expands, especially in states
that have struggled to move the dial because they
have had so many people outside the organized
system of care. As people begin to enter the
health care system, we can begin to address their
many unaddressed or inadequately addressed
health problems. In the earliest years of expanded
coverage, some statistics may appear to worsen
because illnesses that previously went untreated
will now be identied. Yet in the big picture, better
access means better health and better measured
outcomes.
Secondly, in this era of health system change, we
are moving toward a system that reaches out to
people before they become patients. This allows
us to address individual, clinical prevention needs
such as cancer screenings and blood pressure
monitoring but also does something much more
profound. We are beginning to have more of an
ability to look at the root causes of illnesses such
Improving Health Through the
Places We Live, Work, and Play
GEORGES BENJAMIN, M.D.
Executive Director
American Public Health Association
as diabetes and heart disease
and the social determinants
from the quality of local public
schools to the cleanliness of
our air, water and food to the
condition, or lack, of side-
walks, parks and playgrounds
and affordable, safe housing
in our communities that
really make a difference in
peoples health and wellness.
Consider the Catholic
Health Associations work to
expand community benet
activities, demonstrating how
its member hospitals have
broad impact in improving the
health of their communities.
For example, thanks to Bar-
bershop Outreach in Milwaukee, customers receive
cancer screening information while in the barber
chair for a haircut. That effort raises awareness of
prostate and colon cancer prevention and detec-
tion among black men, who are at higher risk and
often face treatment barriers. Places to Call Home
in Corpus Christi, Texas, gives low-income families
the chance to own a home through the Corpus
Christi Affordable Housing Initiative. Healthy Start/
Healthy Families in Oakland, Mich., links rst-time
parents with services to promote healthy child
growth and development and strengthen fami-
lies. CareNet in Toledo, Ohio, gives low-income
residents who dont qualify for government health
programs a membership card opening access to
public and private primary care providers, 42 spe-
cialty areas such as mental health and dental care,
hospital services, medications and transportation.
The success of those programs and services
Commentaries
hinges on community engagement, something
only possible if we know where we are and where
we want to go. Americas Health Rankings
allows
for this by serving as a benchmark that is still the
longest-serving measure we have of the health
of the nation. In the more than two decades of
the rankings, all states have done something
well. Some states have struggled with their over-
arching ranking being near the bottom. Today,
all states have an opportunity to make enormous
progress.
Fortunately, there are steps all of us can take to
improve the health of the nation. Our policymak-
ers should take advantage of the opportunities
to offer health insurance coverage to as many
people as possible us-
ing the many coverage
options that now exist.
Those include expanding
states Medicaid rolls but
also forging partnerships
to ensure communities are
included in conversations
about coverage.
We must connect the
dots about the ways in
which the places we live,
work and play directly af-
fect our health. Policymak-
ers are uniquely positioned
to do that, and to make the
kind of changes to com-
munities that result in better health. At the local
level, meaningful change can be achieved through
actions such as zoning changes, tax incentives and
other initiatives that provide incentives to make
all our neighborhoods healthier. Our policymakers
should lead the way, and Americas Health Rank-
ings
gives them a tool to zero in on the areas

where change is most sorely needed.
Our health care practitioners must begin to
think more broadly, focusing not just on health
but also on those factors that ultimately inuence
health. We have so many therapeutic options for
people who are ill, and no one could dispute that
medicines and classic health care interventions are
benecial. Yet we live in an era when doctors and
nurses can talk to their patients and perhaps write
prescriptions for things like daily exercise and even
returning to school to get a better education.
We know that, for example, women who are
better educated have fewer problems with infant
mortality. Health providers can support educational
activities in their community and can pay attention
to whats happening with their school board even if
their kids may not still be in school. Health provid-
ers should speak out to make sure kids have physi-
cal education in school and that more children can
walk to school instead of taking a bus. Doctors and
nurses should be viewed as community leaders and
should be intimately and passionately involved in
the processes of their communities.
This is a time, also, that calls for public health
practitioners to partner with the medical com-
munity including hospitals, clinicians and new,
integrated health systems such as Accountable
Care Organizations for the type of involve-
ment that results in positive change. The public
health community has a long history of pressing for
improvement and conducting the kind of robust
research that makes the case for how that improve-
ment happens. New partnerships aimed at improv-
ing community health will truly result in measurable
success.
As individuals, we all must do the foundational
things that are in our control in order to improve
our health. Take a daily walk, avoid tobacco, eat a
diet rich in whole grains and, whenever possible,
fresh local produce. Seek help if you have a medi-
cal problem, and reach out for support with mental
health issues as well.
Its no accident the national Community Trans-
formation Grants are expected to improve the lives
of millions of Americans by addressing three main
areas: physical activity, nutrition and tobacco use.
The American Public Health Association is one of
the national organizations working as partners to
those Community Transformation Grant awardees
to help spread the word about model programs.
The programs already emerging clearly illustrate
At the local level,
meaningful change
can be achieved
through actions
such as zoning
changes, tax
incentives and
other initiatives.
the diversity of communities and the individuals
within those communities, and can help inform
health improvement for all of us.
Within months, three college campuses in
Austin, Texas, including the agship University of
Texas with more than 50,000 students and 24,000
faculty and staff, went tobacco-free. Marylands
effort to protect residents from tobacco use and
secondhand smoke exposure have already led to
tobacco-free public properties, including recre-
ational facilities, in Harford County. In New Mexico,
the Las Cruces School District has approved and
is now promoting the use of outdoor school
space during non-school hours in all 25 elemen-
tary schools, giving access to safe play spaces to
11,500 students and their families. Dental practices
throughout southeast Iowa are voluntarily partici-
pating in blood pressure and tobacco screening
and referral training to help more than 300,000
individuals. Youth and elder walking groups are
part of the transformation project led by the So-
phie Trettevick Indian Health Center in Neah Bay,
Wash., helping local residents improve well-being.
Something as seemingly simple as a fun run can
galvanize individuals and become the tipping point
in a community effort that results in lower rates of
chronic disease and better quality of life.
How do we ensure the momentum is not lost?
We encourage progress by measuring our suc-
cesses and gauging those areas that need more
attention. Americas Health Rankings
gives
policymakers, health professionals and individuals
an important tool for that measurement. We can
use the rankings to hold ourselves accountable and
ensure value in our investment in both individual
and community health. Its a call to action and a
roadmap for change. Lets use it!
The World Health Organization denes health as a state of complete
physical, mental and social well-being and not merely the absence of
disease or inrmity.
In addition to the contributions of our individual genetic predispositions
to disease, health is the result of:
Cur behavlors
The envlronmenf and fhe communlfy ln whlch we llve
The pollcles and pracflces ol our healfh care, governmenf and ofher
prevention systems
The cllnlcal care we recelve
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. Understanding these interactions is vital if we are to create
the healthy outcomes we desire, including a long, disease-free, robust
life for all individuals regardless of race, gender, or socio-economic
status. This report focuses on these determinants and on the overall
health outcomes we desire.
At americashealthrankings.org, you can nd information about the
health of your state compared to other states, build custom reports to t your
needs, and download templates and graphs to share with others. Stay informed
throughout the year by signing up for the newsletter and reading the AHR blog.
Keep up with Americas Health Rankings
via Facebook and Twitter. Youll

see how everyone is working in real time to help improve the health of our
communities, workplaces, states, and nation.
Americashealthrankings.org/newsletter facebook.com/AmericasHealthRankings twitter.com/AHR_Rankings
TAKE ACTION
For you and your community
1. Visit americashealthrankings.org/takeaction to learn what
you can do to improve your communitys health.
3. Review results and decide on
the actions you can take.
2. Select what you want to
improve and click Go.
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2012 EDITION
The United Health Foundation provides reliable
information to support health and medical
decisions that lead to better health outcomes
and healthier communities. The Foundation also
supports activities that expand access to quality
health care services for those in challenging
circumstances and partners with others to
improve the well-being of communities.
United Health Foundation
9900 Bren Road East
Minnetonka, MN 55343
www.unitedhealthfoundation.org
is available in its entirety

at www.americashealthrankings.org. Visit the website
to request or download additional copies.
DECEMBER 2012
Our Partners:

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A

is available in its entirety

via Facebook and Twitter. Youll

2012 Edition is available in its entirety at

2012 Edition is a joint effort of United Health

2012 Edition as the source and provide

: A Call to Action for Individuals

provides the longest-

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2012 Edition shows

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reect the condition of the average

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Program began in Los Angeles,

assigns a composite score

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gives them a tool to zero in on the areas

via Facebook and Twitter. Youll

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