U.S. health improvements slowing: Some states better off than others
The 15th annual America’s Health: State Health Rankings study conducted by United Health Foundation says that while the overall health of U.S. residents continues to improve, the rate of improvement has slowed in recent years.
Reed Tuckson, vice president of United Health Foundation, tells State Health Watch it’s true that there is a flattening in progress and some increases in risk factors, and it’s also true that there have been quite a few successes.
The state-by-state analysis shows that some states are doing quite well compared to their counterparts. "Every state has its challenges, and every state has its successes," Mr. Tuckson declares.
In the study, states are scored using federal data according to 18 health indicators in categories of risk behavior, health outcomes, community environment, and health policies.
Overall, the study reports, the health of the nation has increased 17% since 1990, driven in part by smoking-reduction programs. However, overall improvement has slowed in the past five years to just 0.2% annually. The slowdown is driven in part by the growing prevalence of obesity, which has increased 97% since 1990, according to the American Public Health Association’s Georges Benjamin. The association sponsors the report.
Currently, 22.8% of the population has a body mass index of 30 or higher, up from 22.1% last year. Another factor that has slowed improvement is the U.S. infant mortality rate, which last year rose for the first time in 40 years, from 6.9 deaths for every 1,000 live births to seven deaths in the first year of life per 1,000 live births. Overall, the infant mortality rate in this country has fallen 31% since 1990, but still ranks 28th worldwide in infant mortality rates.
In the state-by-state analysis, Minnesota, New Hampshire, and Vermont were rated the healthiest states in the nation, reflecting low rates of poverty and premature death, safer than average drivers, and generous spending on public health programs.
Minnesota, which was ranked first, has been in that position for nine of the last 15 years. Louisiana, Mississippi, and Tennessee were ranked at the bottom of the analysis, reflecting high rates of poverty, infant mortality, and cancer, as well as large numbers of smokers and, except for Tennessee, high uninsured rates.
States face many challenges
In an introductory letter, Julie Gerberding, director of the CDC, said the rankings demonstrate that all states, no matter their successes, still have urgent challenges to confront in achieving optimal health for all their residents. "Disparities in health among American population groups and the escalating epidemic of obesity with its attendant consequences are but two of these urgent challenges," she said.
Ms. Gerberding cautioned that simply documenting shortfalls is not enough. "Committed action will need to be taken if we are to do better," she declared. "CDC supports the report’s call to action and is committed to helping people take action to improve the health of their communities by providing tools and resources that are evidence-based, cross-cutting, and user-friendly."
In a report commentary on infant health, Jennifer Howse and Michael Caldwell wrote that, in 2003, there were 12.6 million women of childbearing age and 9.1 million children younger than 19 who were uninsured. They said uninsured women receive fewer prenatal services and reported greater difficulty in obtaining needed care than women with insurance.
Similarly, health insurance status was the single most important influence in determining whether health care is accessible to children when they need it. One-third of uninsured children have no usual source of medical care, nearly 10 times the rate of those with insurance. Largely responsible for the higher infant mortality rate is the excess contribution of prematurity. Ms. Howse and Mr. Caldwell said risk factors for prematurity include: history of pre-term birth, maternal age, multifetal pregnancy stress, infection, smoking, and obesity. "Many of the causes are still unknown and require continued research," they concluded.
The study’s purpose, according to the report, is to stimulate public conversation concerning health in our states, as well as to provide information to facilitate citizen participation. "We encourage participation in all three elements: personal behaviors, community environment, and health policies," the report said. "Each person, individually and in their capacity as an employee, employer, voter, community follower, health or elected official, can contribute to the advancement of the healthiness of their state, regardless of whether its current standing is first or 50th."
Many of the statewide measures reflect the condition of the average resident, according to the report. However, when those measures are examined more closely, startling differences based on race, sex, and/or economic status may exist.
"Disparities in health outcomes are not only a national issue but also an issue for each state," the report explained. "While each state has unique issues that contribute to disparities, states that have been successful in reducing disparities in health indicators while retaining high overall health can serve as models for other states."
There was good news
Looking at changes from the 2003 report, this year’s study said the overall health of the U.S. population increased 0.6% from 2003 to 2004. The improvement is attributed to a decrease from 23% of the population to 22% in the prevalence of smoking; an increase in the high school graduation rate from 67.3% to 68.3% of incoming ninth graders who graduate within four years; and a decrease in the violent crime rate from 505 to 495 offenses per 100,000 population. Additional factors include an increase in per-capita public health spending from $50 to $59 per person, and an increase in the percent of health dollars allocated to public health from 5.7% to 6.1% of health budget expenditures. These gains were mostly offset by the increases in infant mortality, the prevalence of obesity, and the percentage of children in poverty.
In the state analyses, 22 states had a positive change in their overall score on health, with the largest improvements in Alaska (+8.4 points in overall score), Arizona (+5.1 points), Oklahoma (+4.9 points), and Hawaii (+4.3 points). All other increases were less than 4.0 points.
Principal reasons for the improvements cited were:
- Alaska: Support for public health improved as indicated by increases in per-capita public health spending and the percentage of the state’s health budget spent on public health. Also smoking, infectious diseases, and the infant mortality rate declined.
- Arizona: Prevalence of smoking decreased, percentage of children in poverty decreased, and per- capita public health spending almost doubled.
- Oklahoma: Percentage of children in poverty and incidence of infectious diseases dropped, offsetting increases in obesity and rate of the uninsured population.
- Hawaii: Prevalence of smoking and the percentage of children in poverty declined while the high school graduation rate increased.
The overall scores of 28 states declined from 2003. The states with the largest decreases were South Dakota (-5.2 points in overall score), Washington (-3.8 points), and Oregon (-3.6 points). Other state declines were 3.5 points or less.
Principal reasons for the declines were:
- South Dakota: The rate of motor vehicle deaths increased, the prevalence of obesity increased, and the percentage of children in poverty increased.
- Washington: The percentage of children in poverty increased, the number of limited activity days increased, and the prevalence of smoking decreased.
- Oregon: The rate of uninsured population increased, the percentage of children in poverty increased, and per-capita public health spending declined.
Facilitating citizen action
United Health Foundation’s Reed Tuckson tells SHW the study’s subtitle — A Call to Action for People and Their Communities — is meant to send a message that there is much that individuals and communities can do to improve health status. He says the report section on personal behaviors such as smoking, nutrition, exercise, hypertension control, and high school graduation indicates that people need to make better choices in how they live their lives. The community environment section looks at issues such as infectious diseases, violence, occupational fatalities, and the uninsured and urges people to participate in civic life to ensure community-based resources are robust. "People need to be in touch with their elected officials and participate in discussions of allocation of resources," Mr. Tuckson declares.
Asked why the overall trend is flattening, he explains that people in the United States are not adequately motivated to make health a priority. "It’s perplexing," Mr. Tuckson adds, "because people are concerned about health care costs and access. But they’re not making healthy decisions and behaviors enough of a priority."
[The report is available for free download from www.unitedhealthfoundation.org. Contact Mr. Tuckson at (952) 936-1253.]
The 15th annual Americas Health: State Health Rankings study conducted by United Health Foundation says that while the overall health of U.S. residents continues to improve, the rate of improvement has slowed in recent years.
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