America's Health Rankings
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Selection of Components

Four primary considerations drove the design of America's Health Rankings™ and the selection of the individual components: 

1. The overall rankings had to represent a broad range of issues that affect a population's health, 

2. Individual components needed to use common health measurement criteria, 

3. Data had to be available at a state level and 

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 components of healthiness at this time and are consistent with past reports. 

The Scientific Advisory Committee suggested that the components be divided into two categories - determinants and outcomes.  For further clarity, determinants are divided into four groups: Personal Behaviors, Community Environment, Public and Health Policies and Clinical Care.  These four groups of measures influence 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 four groups.  For example, the prevalence of smoking is a personal behavior that is strongly influenced by the community 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 America's Health Rankings™ to continue to meet its objectives, it must evolve and incorporate new information as it becomes available.  The Scientific Advisory Committee provides guidance for the evolution of the rankings, balancing the need to change with the desire for longitudinal comparability.  Over the last few years, change is being driven by: 1) the acknowledgement that health is more than years lived but includes the quality of those years, 2) data about the quality and cost of health care delivery are becoming available on a comparable basis and 3) measurement of the additional determinants of health are being initiated and/or improved.  The committee also emphasizes that the real impact on health will be made by addressing the health determinants, and making improvements on these items that affect the long-term health of the population.  The determinants are the predictors of our future health. 

This year, three new measures are introduced as health determinants: Binge Drinking (percent of the population who binge drink), Primary Care Physicians (number of primary care physicians per 100,000 population) and Preventable Hospitalizations (discharge rate for Ambulatory Care Sensitive Conditions).  Motor Vehicle Deaths (Deaths per 100,000,000 miles driven), used in all previous editions of the report, has been removed.  

Health outcomes are traditionally measured using mortality measures including premature death, infant mortality, cancer and cardiovascular mortality.  While these measures overlap significantly, they do present different views of mortality outcomes of the population.  Two measures of the quality of life - poor mental health days and poor physical health days - are also included (defined as the number of days in the previous 30 days when a person indicates their activities are limited due to mental or physical health difficulties).  

As with all indices, the positive and negative aspects of each component must be weighed when choosing and developing them.  These aspects for consideration include: 1) the interdependence of the different measures; 2) the possibility of the overall ranking disguising the effects of individual components; 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 components can mitigate their impact (Table 13).

Each component is assigned a weight that determines its percentage of the overall score.  Determinants account for 70 percent of the results, and outcomes account for 30 percent, a shift from the 50/50 balance in the original 1990 index to reflect the importance and growing measurement of determinants.

 

Description of Components

Table 10 is a summary of each of the components in America's Health Rankings™.  A short discussion of each component immediately follows.  The data for each year is the most current data available at the time the report was compiled.

 

Table 10 - Summary Description of Components

 

Determinants Description
Personal Behaviors
Prevalence of Smoking Percentage of population over age 18 that smokes on a regular basis.  This is an indication of known, addictive, health-adverse behaviors within the population. (Table 21)
Binge Drinking Percentage of population over age 18 that has drunken excessively in the last 30 days.  Binge drinking is defined as 5 drinks for a male and 4 for a female in one setting.  It is a proxy indicator for excessive drug and alcohol use within a population. (Table 22)
Prevalence of Obesity Percentage of the population estimated to be obese, with a body mass index (BMI) of 30.0 or higher. Obesity is known to contribute to a variety of diseases, including heart disease, diabetes and general poor health.  (Table 23)
High School Graduation As reported by NCES in compliance with the No Child Left Behind initiative.  Percentage of students who graduate in four years from a high school with a regular degree.  It is an indication of the consumer's ability to learn about, create and maintain a healthy lifestyle and to understand and access health care when required. (Table 24)
Community Environment
Violent Crime The number of murders, rapes, robberies and aggravated assaults per 100,000 population.  It reflects an aspect of overall lifestyle within a state and its associated health risks.  (Table 25)
Occupational Fatalities Number of fatalities from occupational injuries per 100,000 workers.  This measure reflects job safety as a part of public health. (Table 26)
Infectious Disease Number of AIDS, tuberculosis and hepatitis cases reported to the Centers for Disease Control and Prevention per 100,000 population.  This is an indication of the toll that infectious disease is placing on the population.  (Table 28)
Children in Poverty The percentage of persons under age 18 who live in households at or below the poverty threshold.  Poverty is an indication of the lack of access to health care by this vulnerable population.  (Table 27)
Public & Health Policy
Lack of Health Insurance Percentage of the population that does not have health insurance privately, through their employer or the government.  This is an indicator of the ability to access care as needed, especially preventive care.  (Table 29)
Per Capita Public Health Spending The dollars spent on direct public health care services, community-based services and population health activities as defined by NASBO.  This indicates the actual financial commitment a state has made to public health. (Table 30)
Immunization Coverage Percentage of children ages 19 to 35 months who have received four or more doses of DTP, three or more doses of poliovirus vaccine, one or more doses of any measles-containing vaccine, three or more doses of HiB, and three or more doses of HepB vaccine. (Table 31)
Health Services
Adequacy of Prenatal Care Percentage of pregnant women receiving adequate prenatal care, as defined by Kotelchuck's Adequacy of Prenatal Care Utilization (APNCU) Index.  This measures how well women are receiving the care they require for a healthy pregnancy and development of the fetus. (Table 32)
Primary Care Physicians Number of primary care physicians (including general practice, family practice, OB-GYN, pediatrician and internists) per 100,000 population.  This measure reflects the availability of physicians to assist the population with preventive and regular care. (Table 33)
Preventable Hospitalizations Discharge rate among the Medicare population for diagnoses that are amenable to non-hospital based care. This reflects the effectiveness that a population uses the various delivery sites for necessary care. (Table 34)
Outcomes Description
Poor Mental Health Days Number of days in the previous 30 days when a person indicates their activities are limited due to mental health difficulties.  This is a general indication of the population's ability to function on a day-to-day basis. (Table 35)
Poor Physical Health Days Number of days in the previous 30 days when a person indicates their activities are limited due to physical health difficulties.  This is a general indication of the population's ability to function on a day-to-day basis. (Table 36)
Infant Mortality  Number of infant deaths (before age 1) per 1,000 live births.  This is an indication of the prenatal care, access and birth process for both child and mother. 
(Table 37)
Cardiovascular Deaths Number of deaths due to all cardiovascular diseases, including heart disease and strokes, per 100,000 population.  This is an indication of the toll that these types of diseases place on the population. (Table 38)
Cancer Deaths Number of deaths due to all causes of cancer per 100,000 population.  This is an indication of the toll cancer is placing on the population.  (Table 39)
Premature Death Number of years of potential life lost prior to age 75 per 100,000 population.  This is an indication of the number of useful years of life that are not available to a population due to early death.  (Table 40)