The Health of the Nation: State By State

Vermont's on top and Mississippi's on the bottom of the United Health Foundation rankings. What factors were considered?

Minnesota residents drink too much, but they have a low premature death rate. Mississippians don't overindulge, but only a fifth of the population has health insurance. And Vermont seems to be under a lucky star—few uninsured residents, a very low rate of infectious diseases, and a low premature death rate.

These are some of results revealed in the 18th annual America's Health Rankings report comparing Americans' health, state by state. It was released by the United Health Foundation (UHF) Nov. 5. The UHF, which was founded by the UnitedHealth group in 1999, publishes the report in partnership with the American Public Health Assn. and Partnership for Prevention.

The UHF said that Americans' overall health has declined by 0.3% as measured by key health indicators, despite progress made in several areas such as reduced cancer rates. It cited factors such as obesity, an increasing number of uninsured people, and the "persistence of risky health behaviors such as tobacco use and binge drinking."

Behind the Methodology

In a statement, the UHF said that America's Health Rankings looks at 18 factors to decide which states are healthiest. These include a state's number of smokers, infant mortality rates, per capita public health spending, and immunization coverage.

The UHF also said that the 18 measures "reflect three essential contributors to health": decisions made by individuals to promote health and prevent disease, the community environment that affects individuals' health, and public health policies that affect the availability of public health and medical resources.

Reed Tuckson, the principal clinical sponsor of the report for the UHF, said the rankings should encourage individuals to "make appropriate personal health choices, actively support local community-based organizations and institutions, and advocate with elected and public health officials for necessary resources."

A Critic's Reaction

Not everyone thinks the rankings make sense. The September, 2007, issue of the Southern Medical Journal published a letter from Lee Friedman, a research assistant professor at the University of Illinois at Chicago's School of Public Health. "The recent America's Health Rankings," Friedman wrote, "represents just another attempt at creating global measures of health, which inevitably results in junk science."

The problem, Friedman continued, is "ignoring the role of poverty and the environmental and social disadvantages of lower income Americans leads to the wrong conclusion about geographic disparities in health and will likely mislead important state and federal policymakers…The study only promotes stereotypes and disparaging views of the poor states, which are disproportionately located in the South."

Dr. Tuckson said, "We are encouraged by any reactions that stimulate attentiveness to the promotion of health and the prevention of disease. I appreciate the absolute importance of socioeconomic status on individual health and the ability of states to mount effective campaigns."

He continued, "We look at the percentage of children in poverty as one of our measures. It is also exceedingly important to know the rate of tobacco use in a state and in the country—whether progress is being made in the number one most preventable risk factor in death and disease. And a health care issue like obesity, he said, is important "in its own right, independent of socioeconomic status."

Racial Disparities

Aside from state-by-state comparisons, America's Health Rankings pointed out racial disparities among healthy and unhealthy Americans. The premature death rate for black Americans is almost 1.5 times the rate for whites (the Centers for Disease Control and Prevention defines premature death as the loss of years of productive life due to death before age 75).

The UHF also said that Hispanics receive poorer quality care than non-Hispanics and that "the data indicate that this trend is getting worse, not better." And in terms of preventive care, the UHF said the Hispanic population has the lowest percentage of people availing themselves of regular dental care and colon cancer screenings—"two key indicators of a population's ability to stay healthy."

Looking Forward

Dr. Tuckson said that in the end, "It's progress that we're looking for." He cited South Carolina as an example of a state that had improved in the rankings, from 48th on the list in 2006 to 42nd in 2007.

"Every state, regardless of where it ranks, has its share of challenges," he continued. "And every state has its share of successes. From our way of thinking, it's not particularly important which state is number one and which state is number 50."

He encouraged Americans to get involved with their communities and cited Vermont as an example. "The attitude that we take is that this data is important in highlighting key issues, but we also encourage states and communities and citizens to get with their local health departments…so they can get even more specific about the exact problems and priorities where they live."

Galland is an editor at BusinessWeek .