Methodology

The methodology underlying America's Health: State Health Rankings reflects the evolving expectations and role of health in our society and our ability to measure various aspects of health. The methodology has evolved over the report's 15-year history to capture these changes, however we have strived to maintain comparability among editions and to provide a useful resource for tracking and evaluating progress.

The tables that present each component contain three columns: rank, data and score. They are calculated as follows:

The data are the raw data as obtained from the stated sources and adjusted for age, race and/or population as appropriate. Supporting data are presented in the Appendix. All age-adjusted data utilizes the population profile for the middle year of data. For example, if the data are from 1998 to 2000, the standard population is set at 1999.

The score for each state is based on the following formula. The score is stated as a percentage.

This calculation results in a score of 0.0 for a state with the same value as the national average. States that have a higher value than the national average will have a positive score while those with lower values will have a negative score.

To prevent an extreme value from excessively influencing a final score, the maximum score any state could receive for a component is limited to the national norm plus or minus two standard deviations.

For several measures, such as Infant Mortality and Infectious Disease, the data from multiple years are combined to provide sufficient sample size to be meaningful.

Where a value for the United States overall is not available, the national average is set at the average value of the states measured.

The overall score was calculated by adding the scores of each component multiplied by its weight (percent of total overall ranking). Note: Scores reported for individual components may not add up to the overall scores due to the rounding of numbers.

The ranking is the ordering of each state according to score. Ties in scores are assigned equal rankings.

Components adjusted for race include black and white races only. Other races have been excluded due to data limitations. Where mortality data for blacks is unreliable due to low counts, the national average for blacks is used. These states are marked by an asterisk in the Component Tables.

All earlier results have been revised to correct any errors discovered since release of the prior editions.

Methodology Review

In 2002, the 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 ongoing review of the America's Health: State Health Rankings. The team, led by Thomas Ricketts, Ph.D., was charged with conducting a thorough review of the current index and recommending improvements that would maintain the value of the comparative information and reflect the evolving role and science of public health. Minor issues are always addressed immediately and incorporated into the contents of the report. However, more significant issues, such as new measurements of health conditions, require more in-depth study and analysis. Several changes in the methodology were made to the 2002 and 2004 Editions at the recommendation of the panel.

Continuing their review, the group convened again in May 2004 to review and discuss the methodology and components used in this analysis. The group did recommend changes to the methodology for the 2004 Edition.

The group continued to emphasize the importance of this tool as a vehicle to promote and improve the general discussion of public health and to encourage balance among public health efforts to benefit the entire community. Wisconsin, in a ranking of counties, has adopted a visual model that has been very helpful in communicating with the public. This starting point was modified to reflect the uniqueness of the state rankings and is used to present information in this report. The model is described in the introduction of this report.

Also, in support of this focus, the group recommended the replacement of the old measure, Risk for Heart Disease, with a new measure, Prevalence of Obesity. The prior measure wrapped three risk factors for heart disease (obesity, inactivity and hypertension) into one composite measure and did not allow focus and discussion of the individual measures. In light of the continuing evidence of the profound impact of obesity on heart disease, it was decided to shift the measure to focus on obesity. In addition, the panel recommended expanding the prior Heart Deaths measure to include all cardiovascular deaths to allow it to include strokes and similar causes of death. The panel also received information that the data about public health expenditures, collected by the National Association of State Budget Officers, is reliable, and it should become more visible in the overall index. Accordingly, the old Support for Public Health Care measure, which was the ratio of the percent of health care expenditures divided by the percent of the population with moneyed income under $15,000, be replaced by two measures: Per Capita Public Health Spending and Percent of Health Dollars for Public Health. The two measures would retain the same weight as the prior measure, but allow more focus on actual spending. These new measures are discussed in the section labeled Components.

The group represented a variety of interests ranging from state health offices, CDC and APHA, as well as the academic disciplines. Panel members include:

Thomas E. Ricketts, Ph.D.
Professor of Health Policy and Administration and Social Medicine
Deputy Director, Cecil G. Sheps Center for Health Services Research
University of North Carolina - Chapel Hill

Dennis P. Andrulis, Ph.D., MPH
Director of the Office of Urban Populations
New York Academy of Medicine
SUNY Downstate Medical Center

Georges Benjamin, M.D.
Executive Director
American Public Health Association

John Booker, Ph.D.
Associate Director, Public Health Practice
Institute for Public Health
University of New Mexico

William Dow, Ph.D.
Assistant Professor
Department of Health Policy and Administration
School of Public Health
University of North Carolina at Chapel Hill

Jonathan Fielding, M.D., M.P.H., M.B.A., M.A.
Professor of Health Services and Pediatrics
School of Public Health
University of California - Los Angeles
Director of Public Health and Health Officer
Los Angeles County, California

Marthe Gold, M.D.
Logan Professor and Chair, Department of Community Health
Medical School
City University of New York

Dave Kindig, M.D., Ph.D.
Professor of Population Health Sciences and
Director, Wisconsin Institute for Public Health and Health Policy
University of Wisconsin-Madison, School of Medicine

Jeffrey Koshel, M.A.
Deputy Division Director
MCHB/DSCH-HRSA

John Lynch, Ph.D., M.P.H., M.Ed.
Assistant Research Scientist
Department of Epidemiology
School of Public Health
University of Michigan

Matthew McKenna, M.D., M.P.H.
Medical Officer
Centers for Disease Control and Prevention
Atlanta, Georgia

Catherine Michaud, M.D., Ph.D.
Senior Research Associate
Center for Population and Development Studies
Harvard University

Patrick Remington, M.D., M.P.H.
Associate Professor in the Department of Population Health Sciences
Associate Director of the Comprehensive Cancer Center for Outreach and Population Studies
Department of Population Health Sciences
University of Wisconsin-Madison

Leiyu Shi, Ph.D.
Associate Professor, Department of Health Policy and Management
Associate Director, Primary Care Policy Center
School of Public Health
Johns Hopkins University

Steven Teutsch, M.D., M.P.H.
Executive Director
Outcomes Research and Management
Merck & Co., Inc.

Susan Zelt, M.P.H., M.B.A.
Department of Health Policy and Administration / Public Health Leadership
School of Public Health
University of North Carolina at Chapel Hill

Tom Eckstein
Principal
Arundel Street Consulting, Inc.