Investing in ISSUE REPORT America’s Health: 2014 A STATE-BY-STATE LOOK AT PUBLIC HEALTH FUNDING AND KEY HEALTH FACTS MAY 2014 Acknowledgements Trust for America’s Health is a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority. For more than 40 years the Robert Wood Johnson Foundation has worked to improve the health and health care of all Americans. We are striving to build a national culture of health that will enable all Americans to live longer, healthier lives now and for generations to come. For more information, visit www.rwjf.org. Follow the Foundation on Twitter at www.rwjf.org/twitter or on Facebook at www.rwjf.org/facebook TFAH would like to thank RWJF for their generous support of this report. TFAH BOARD OF DIRECTORS Gail Christopher, DN David Fleming, MD President of the Board, TFAH Director of Public Health Vice President for Program Strategy Seattle King County, Washington WK Kellogg Foundation Arthur Garson, Jr., MD, MPH Cynthia M. Harris, PhD, DABT Director, Center for Health Policy, Vice President of the Board, TFAH University Professor, Director and Professor And Professor of Public Health Services Institute of Public Health, Florida University of Virginia A&M University John Gates, JD Theodore Spencer Founder, Operator and Manager Secretary of the Board, TFAH Nashoba Brook Bakery Senior Advocate, Climate Center Tom Mason Natural Resources Defense Council President Robert T. Harris, MD Alliance for a Healthier Minnesota Treasurer of the Board, TFAH Alonzo Plough, MA, MPH, PhD Former Chief Medical Officer and Senior Vice President for Research and Evaluation Vice President for Healthcare and Chief Science Officer BlueCross BlueShield of North Carolina Robert Wood Johnson Foundation Barbara Ferrer, PhD, MPH, ED Eduardo Sanchez, MD, MPH Health Commissioner Deputy Chief Medical Officer Boston, Massachusetts American Heart Association REPORT AUTHORS Jeffrey Levi, PhD Laura M. Segal, MA Executive Director Director of Public Affairs Trust for America’s Health Trust for America’s Health and Professor of Health Policy Rebecca St. Laurent, JD Milken Institute School of Public Health at the Health Policy Research Manager George Washington University Trust for America’s Health 2 TFAH • healthyamericans.org Investing in INTRODUCTION Introduction America’s For too long, the country has focused on treating people Health after they become sick instead of preventing diseases before they occur. Public Health Investing in disease prevention is The nation’s public health system Report the most effective, common-sense is responsible for improving the series way to improve health — helping to health of Americans. But, the public spare millions of Americans from health system has been chronically developing preventable illnesses, underfunded for decades. Analyses reduce healthcare costs and improve from the Institute of Medicine the productivity of the American (IOM), The New York Academy of workforce so we can be competitive Medicine (NYAM), the U.S. Centers with the rest of the world. for Disease Control and Prevention (CDC) and a range of other experts Tens of millions of Americans are have found that federal, state and currently suffering from preventable local public health departments have diseases such as cancer, heart disease been hampered due to limited funds and diabetes. And, today’s children and have not been able to adequately are in danger of becoming the first carry out many core functions, generation in American history to including programs to prevent disease live shorter, less healthy lives than and prepare for health emergencies.1 their parents. In this report, the Trust for America’s Health (TFAH) examines public health funding and key health facts in states around the country. The report provides the public, encourages greater transparency policymakers and a broad and diverse and accountability of the system; set of groups involved in public and recommends ways to assure the health with an objective, nonpartisan, public health system meets today’s independent analysis of the status needs and works across boundaries to of public health funding policies; accomplish its goals. MAY 2014 MAIN FINDINGS l lat Federal Funding: Federal F l A ccording to a 2013 report by the Change in CDC Budget from 2005 – 2013 funding for public health has Association of State and Territorial remained at a relatively flat level Health Officials (ASTHO), 48 states, $7.07 billion $5.98 billion for years. The budget for CDC has three territories and Washington, decreased from a high of $7.07 D.C. have reported budget cuts, and billion in Fiscal Year (FY) 2005 to 91 percent of all state and territorial 15% $5.98 billion in FY 2013. 2 Spending health agencies (SHAs) experienced through CDC averaged to only $18.92 job losses through a combination 2005 2013 per person in FY 2013. And the of layoffs and attrition. SHAs have amount of federal funding spent to also reported cuts to programs, Change in Median per Capita State prevent disease and improve health including to public health hospitals Spending from 2008 – 2013 in communities ranged significantly and clinics; HIV/AIDS and sexually $33.17 from state to state, with a per capita transmitted disease prevention $27.49 low of $13.67 in Indiana to a high of services; disease specific programs; $46.48 in Alaska. family health and nutrition programs; maternal and child health programs; 17% l uts in State and Local Funding: C tobacco prevention and control; At the state and local levels, public immunizations; and for programs health budgets have been cut for children with special healthcare 2008 2013 at drastic rates in recent years. needs. Fifteen SHAs reported cuts to According to a TFAH analysis, their FY 2013 budgets.3 33 states and Washington, D.C. decreased their public health budgets l D uring 2012, close to one-half from FY 2011-12 to FY 2012-13. (48 percent) of all local health Budgets in 20 states decreased for two departments (LHDs) reduced or more years in a row, and budgets or eliminated services in at least in 16 states decreased for three or one program area. Immunization, more years in a row. In FY 2012-13, maternal and child health and the median state funding for public emergency preparedness services health was $27.49 per person, ranging were the three most affected During 2012, close to one- from a high of $144.99 in Hawaii program areas. Since 2008, LHDs half (48 percent) of all local to a low of $5.86 in Missouri. From lost almost 44,000 jobs, and 31 health departments reduced or FY 2008 to FY 2013, the median per percent of all LHDs expect cuts in capita state spending decreased from the upcoming fiscal year.4 eliminated services in at least $33.71 to $27.49. This represents a one program area. cut of more than $1.3 billion adjusted for inflation. 4 TFAH • healthyamericans.org l ide Variation in Health Statistics W identify factors that influence health, Percent of Adults Who Have Diabetes— by State: There are major outside of the doctor’s office. The Alaska vs. West Virginia differences in disease rates and rankings do not currently include other health factors in states around budget data by county. 7% of adults in Alaska have diabetes the country. For instance, only 7.0 Public health departments have the percent of adults in Alaska have unique role and responsibility as chief 13% of adults in West Virginia have diabetes diabetes compared to 13.0 percent health strategist for communities — in West Virginia and 28.3 percent working to improve health in schools, of adults in Kentucky are current Percent of Adults Who are Smokers— workplaces and neighborhoods. This Kentucky vs. Utah smokers while only 10.6 percent involves identifying the top health report smoking in Utah. Kentucky problems and developing strategies 28.3% l ide Variation in Health Statistics W for how to address them. To be Utah 10.6% by County: There are also major effective, public health officials must differences in disease rates and have the capabilities to define the health factors within each state. scope of health problems, set goals to County Health Rankings, published improve health and recruit whoever by the Robert Wood Johnson can help make change happen. Foundation (RWJF) and University In 2014, the public health field faces of Wisconsin Population Health a sea change. A reforming health Institute, provide county-level data system, massive budget cuts, an on a number of key health factors for increased focus on accountability and nearly every county in the country. the growing adoption of electronic The rankings assess health behaviors health records (EHRs) are creating (tobacco use, diet, alcohol use, etc.), new challenges and opportunities. clinical care (access to and quality of care), social and economic factors Historically, the exact services (such as education, employment and and programs that public health income) and physical environment departments provide can be different (environmental quality and the depending on where you are in built environment such as housing the country. And, the structures, and transportation).  The Rankings budgets and sets of responsibilities highlight the healthiest and least can vary significantly based on the healthy counties in every state and state and county. TFAH • healthyamericans.org 5 This report examines some key disease rates in combination with health spending to help further the discussion about what the right amount of public health funding should be in order to have a real impact on reducing disease rates nationally. Two recent projects have stressed that Because of federal funding limita- to adapt to the modern challenges tions, many states submit competitive they face, public health departments grants that are “approved but un- must have a stronger focus on their funded” due to limited funds. In most unique and most effective capabilities. cases, there is no official strategy for Both the IOMs For the Public’s Health: targeting or coordinating these funds. Investing in a Healthier Future report Also, state and local funding varies and a group of thought-leaders who dramatically, largely due to the differ- comprised the Transforming Public ent structures of a state’s public health Health project, funded by RWJF and department. Some departments are convened by RESOLVE, identified centralized, while others are decentral- foundational capabilities for public ized wherein responsibilities rest more health.5, 6 (See the Investing in on local departments than at the state America’s Health report supplement level. However, states and localities for a summary of the public health also place different priorities on public foundational capabilities and public health, which accounts for differences health accreditation initiatives). in funding. The state-by-state compari- But, federal public health programs, sons included in this report’s budget as currently structured, do not actively analysis do not include county or city promote a set of baseline, consistent revenues that are generated to support capabilities that every community local health departments, which are across the country should be able also quite variable. to achieve. There is little strategic Overall, the report concludes that rationale for the way public health a sustained and sufficient level of is funded in America, including for investment in prevention at all the variances in funding for different levels of government is essential places around the country. Federal to improving health in the United funding is based on a mixture of pop- States, and that differences in disease ulation-based formula grant programs rates will not be changed unless an (often based on disease rates or other adequate level of funding is provided incidence formulas) and a series of to support public health departments competitive grants - where some states and disease prevention efforts. receive funding and others do not. 6 TFAH • healthyamericans.org SECTI O N 1: State Rates SECTION 1: FUNDING FOR PUBLIC HEALTH Funding for Public Health Public health programs are funded through a and Trends combination of federal, state and local dollars. Each level of government has different, available. There is a significant but important responsibilities for delay from the time a President protecting the public’s health. While proposes a fiscal year budget to when this report focuses primarily on federal appropriations legislation is signed funding to states, it also provides into law to the time when the funds are information about state funding. disbursed. TFAH uses FY 2013 data for this analysis, which is the most recent TFAH analyzes federal and state budget year for which the data is most funding for public health based on the complete and accurate. most complete financial data currently A. FEDERAL INVESTMENTS IN PUBLIC HEALTH FEDERAL FUNDING FOR STATES FROM THE U.S. CENTERS FOR DISEASE CONTROL AND PREVENTION Approximately 75 percent of CDC’s formula for priority programs. Other budget is distributed to states, localities funds are based on competitive grants. and other public and private partners States can apply to CDC for funding to support services and programs. for specific program areas. Often in MAY 2014 Most of the federal funding from CDC these cases, not all states that apply for is distributed by categories. Some of funds receive them because there are CDC’s funding is based on the number insufficient funds appropriated to allow of people in a state or on a need-based all states to receive grants. CDC FUNDING BY STATE Birth Defects and Agency for Toxic Developmental Chronic Disease Substances and Environmental Infectious Injury Prevention Occupational PHPF/Other ACA State Disabilities, Prevention and Disease Registry Health Diseases and Control Safety & Health Funds Disabilities and Health Promotion (ATSDR) Health Alabama $0 $2,090,916 $9,552,382 $256,690 $13,949,505 $497,862 $1,483,791 $1,565,363 Alaska $260,246 $926,435 $11,223,624 $0 $4,166,201 $702,819 $70,193 $1,927,641 Arizona $223,040 $1,676,583 $9,598,228 $189,135 $15,739,160 $975,202 $905,016 $2,902,306 Arkansas $226,787 $1,711,315 $7,434,563 $0 $6,984,202 $303,725 $724,920 $1,118,489 California $655,364 $3,389,559 $25,539,449 $4,280,900 $127,381,612 $6,245,416 $8,693,622 $33,408,649 Colorado $278,038 $2,985,094 $12,466,969 $307,975 $17,145,152 $2,733,584 $4,408,242 $2,559,183 Connecticut $431,189 $186,016 $5,112,638 $487,148 $13,809,468 $372,282 $1,594,327 $2,869,238 Delaware $0 $393,246 $3,618,545 $0 $4,206,364 $438,193 $0 $4,256,666 D.C. $1,607,034 $4,787,174 $11,347,976 $1,784,017 $27,579,145 $1,336,944 $1,917,892 $4,891,515 Florida $443,878 $593,136 $12,963,692 $805,677 $66,732,815 $2,997,858 $1,624,997 $6,089,438 Georgia $167,461 $1,094,908 $20,903,911 $969,866 $38,594,389 $3,138,770 $632,863 $7,780,863 Hawaii $0 $196,257 $3,698,697 $523,003 $5,639,710 $283,505 $0 $1,641,030 Idaho $219,879 $57,573 $5,470,867 $0 $3,590,600 $573,280 $0 $394,978 Illinois $638,692 $5,554,593 $14,805,724 $603,604 $38,748,977 $3,062,314 $3,316,562 $10,678,943 Indiana $0 $230,620 $6,252,177 $371,777 $11,182,613 $1,038,549 $201,663 $1,213,899 Iowa $0 $2,412,598 $8,507,035 $276,253 $5,709,180 $1,111,973 $4,924,099 $5,049,407 Kansas $0 $20,327 $7,100,472 $60,842 $5,735,440 $567,622 $0 $1,273,484 Kentucky $0 $328,290 $8,419,131 $328,200 $7,132,294 $1,283,193 $2,685,854 $2,688,500 Louisiana $268,100 $342,446 $6,254,017 $450,781 $15,906,022 $972,136 $175,615 $4,636,497 Maine $0 $122,891 $5,714,596 $667,446 $4,336,150 $138,363 $133,404 $3,269,026 Maryland $0 $3,123,939 $14,747,859 $1,944,661 $31,970,358 $3,691,028 $7,881,968 $4,776,358 Massachusetts $402,895 $2,130,609 $10,267,751 $741,735 $23,359,409 $1,897,078 $8,630,495 $12,961,134 Michigan $415,276 $1,748,839 $21,384,334 $715,859 $23,387,443 $4,443,496 $3,888,417 $3,496,758 Minnesota $436,860 $503,460 $12,048,071 $967,619 $16,454,442 $1,379,716 $4,376,270 $9,128,883 Mississippi $0 $327,138 $9,697,369 $464,614 $11,676,549 $309,077 $67,270 $876,559 Missouri $331,895 $909,493 $8,833,648 $507,161 $13,192,346 $1,418,476 $686,535 $3,003,749 Montana $0 $454,182 $6,633,838 $354,200 $3,068,164 $103,058 $98,824 $4,139,969 Nebraska $0 $112,854 $8,551,804 $166,675 $4,662,182 $481,745 $1,876,455 $2,039,274 Nevada $0 $583,866 $5,434,755 $10,000 $6,588,184 $281,292 $0 $824,151 New Hampshire $299,659 $798,999 $5,334,698 $764,534 $3,531,100 $137,125 $120,000 $1,568,415 New Jersey $524,292 $6,406,769 $7,848,520 $409,560 $35,685,767 $1,102,104 $426,386 $3,354,082 New Mexico $1,000,000 $142,053 $6,710,121 $483,414 $7,907,783 $387,005 $867,457 $4,187,333 New York $1,837,102 $5,160,770 $24,748,912 $2,720,289 $117,462,879 $5,734,128 $4,946,346 $19,681,833 North Carolina $263,712 $3,829,261 $14,271,002 $593,661 $22,988,245 $4,269,358 $2,699,796 $10,454,981 North Dakota $0 $455,704 $3,849,117 $0 $2,825,698 $70,058 $0 $745,341 Ohio $613,108 $663,897 $10,180,887 $690,742 $22,409,293 $3,253,360 $3,504,454 $3,834,773 Oklahoma $0 $618,249 $6,908,008 $534,689 $7,682,981 $895,151 $551,882 $2,420,164 Oregon $482,171 $547,058 $9,784,606 $1,033,532 $12,246,255 $1,675,669 $1,894,899 $3,829,582 Pennsylvania $455,685 $1,329,288 $13,056,110 $385,035 $36,535,957 $3,237,356 $997,857 $5,339,601 Rhode Island $0 $851,731 $6,490,078 $920,631 $4,899,154 $842,083 $0 $624,311 South Carolina $0 $4,306,109 $10,652,463 $0 $15,347,060 $681,986 $0 $6,246,354 South Dakota $0 $95,883 $4,902,074 $0 $3,472,827 $294,800 $0 $994,612 Tennessee $205,360 $1,545,540 $5,594,216 $500,000 $18,012,449 $899,518 $162,638 $1,767,863 Texas $341,070 $704,773 $13,988,476 $388,840 $72,328,849 $4,001,871 $3,144,970 $17,211,000 Utah $217,145 $1,561,647 $8,349,107 $391,147 $7,218,107 $1,353,611 $1,525,020 $2,637,086 Vermont $0 $165,000 $4,102,629 $510,476 $4,096,673 $65,178 $0 $2,228,131 Virginia $383,412 $409,583 $8,838,919 $699,654 $21,472,814 $2,248,404 $2,171,272 $6,790,075 Washington $536,552 $246,794 $14,458,332 $1,980,761 $19,642,008 $1,865,964 $5,274,195 $7,567,851 West Virginia $0 $0 $7,853,886 $370,862 $4,118,432 $987,672 $314,962 $3,737,097 Wisconsin $530,867 $1,365,736 $8,564,676 $640,069 $13,087,366 $795,121 $2,514,906 $7,865,357 Wyoming $0 $141,924 $2,897,315 $0 $2,807,850 $58,708 $0 $235,859 U.S. TOTAL $14,696,769 $70,341,125 $492,968,274 $32,253,734 $1,024,407,623 $77,634,786 $92,116,334 $254,783,651 8 TFAH • healthyamericans.org Public Health Preventive Public Health Cross-Cutting Public Health and Social World Trade CDC Per Health and Preparedness Vaccines for Activities CDC Total CDC Per State Scientific Services Center Health Capita Health Services & Emergency Children and Program (All Categories) Capita 2013 Services Emergency Program Fund Ranking Block Grant Response Support Fund Alabama $1,138,472 $8,946,889 $376,806 $56,514,647 $300,000 $277 $0 $96,673,600 $20.00 26 Alaska $323,876 $4,176,943 $442,911 $9,695,512 $250,000 $0 $0 $34,166,401 $46.48 1 Arizona $970,264 $11,609,303 $428,057 $76,838,019 $700,000 $240,821 $0 $122,995,134 $18.56 32 Arkansas $643,028 $6,437,482 $332,379 $38,742,657 $300,000 $0 $0 $64,959,547 $21.95 18 California $5,161,505 $60,227,334 $1,696,065 $395,913,552 $89,694 $1,208,306 $0 $673,891,027 $17.58 38 Colorado $975,301 $9,465,200 $553,688 $39,308,692 $400,000 $0 $0 $93,587,118 $17.76 36 Connecticut $1,030,622 $7,511,728 $408,448 $36,398,317 $300,000 $30,353 $305,205 $70,816,626 $19.69 28 Delaware $137,282 $4,309,494 $244,769 $10,126,936 $250,000 $0 $0 $27,981,495 $30.23 4 D.C. $587,350 $8,291,013 $6,811,200 $9,823,043 $1,280,972 $450,000 $305,205 $82,800,480 $128.09 N/A Florida $2,257,597 $27,530,560 $349,769 $189,984,641 $13,854 $0 $0 $312,387,912 $15.98 44 Georgia $2,572,896 $16,271,688 $3,689,453 $112,571,836 $1,392,519 $832,642 $0 $210,614,065 $21.08 21 Hawaii $550,794 $4,763,065 $447,029 $13,271,873 $0 $0 $0 $31,014,963 $22.09 15 Idaho $272,064 $4,902,137 $357,141 $17,219,674 $300,000 $0 $0 $33,358,193 $20.69 22 Illinois $1,831,436 $26,336,448 $528,945 $129,702,250 $800,000 $0 $0 $236,608,488 $18.37 33 Indiana $1,425,543 $11,086,768 $226,002 $56,168,536 $400,000 $0 $0 $89,798,147 $13.67 50 Iowa $929,134 $6,857,966 $232,665 $25,424,055 $300,000 $0 $0 $61,734,365 $19.98 27 Kansas $805,381 $6,708,826 $429,142 $25,174,085 $300,000 $0 $0 $48,175,621 $16.65 42 Kentucky $1,095,856 $8,424,858 $124,546 $45,329,520 $300,000 $0 $0 $78,140,242 $17.78 35 Louisiana $2,165,189 $8,773,689 $1,258,884 $59,568,548 $1,009,195 $40,397 $0 $101,821,516 $22.01 16 Maine $758,519 $4,848,530 $358,985 $13,339,778 $0 $125,511 $0 $33,813,199 $25.46 9 Maryland $1,383,252 $14,275,702 $9,143,889 $57,255,087 $400,000 $171,019 $0 $150,765,120 $25.43 10 Massachusetts $1,967,223 $13,404,201 $533,607 $60,151,148 $405,342 $142,687 $0 $136,995,314 $20.47 24 Michigan $3,005,670 $16,092,816 $313,107 $87,281,393 $1,136,345 $105,034 $0 $167,414,787 $16.92 40 Minnesota $1,921,488 $11,456,279 $538,832 $35,682,767 $0 $125,274 $0 $95,019,961 $17.53 39 Mississippi $1,027,847 $6,441,849 $328,720 $38,346,109 $300,000 $79,278 $0 $69,942,379 $23.38 12 Missouri $1,862,770 $10,696,227 $276,052 $54,687,937 $400,000 $81,625 $0 $96,887,914 $16.03 43 Montana $553,485 $4,062,430 $350,220 $7,901,368 $250,000 $100,535 $0 $28,070,273 $27.65 6 Nebraska $1,227,628 $5,367,026 $495,950 $15,709,833 $0 $100,075 $0 $40,791,501 $21.83 19 Nevada $300,536 $6,781,224 $415,881 $30,529,051 $300,000 $100,110 $0 $52,149,050 $18.69 31 New Hampshire $1,068,018 $4,883,863 $372,692 $7,825,539 $250,000 $60,912 $0 $27,015,554 $20.41 25 New Jersey $2,130,123 $15,153,565 $452,935 $65,151,366 $79,562 $0 $999,927 $139,724,958 $15.70 45 New Mexico $985,796 $6,611,724 $482,218 $37,989,914 $300,000 $0 $0 $68,054,818 $32.64 3 New York $4,910,518 $37,139,328 $1,805,155 $201,614,063 $1,109,929 $199,962 $17,593,330 $446,664,544 $22.73 14 North Carolina $1,956,510 $14,905,122 $450,549 $97,761,189 $0 $106,553 $0 $174,549,939 $17.72 37 North Dakota $213,708 $3,907,640 $257,847 $5,798,579 $0 $109,286 $0 $18,232,978 $25.20 11 Ohio $3,217,722 $17,525,243 $678,295 $96,763,793 $500,000 $114,307 $0 $163,949,874 $14.17 49 Oklahoma $682,133 $7,769,619 $826,606 $55,499,017 $300,000 $0 $0 $84,688,499 $21.99 17 Oregon $534,849 $7,724,660 $534,632 $29,968,009 $250,000 $0 $0 $70,505,922 $17.94 34 Pennsylvania $3,397,551 $19,136,646 $518,468 $101,276,768 $500,000 $0 $0 $186,166,322 $14.57 48 Rhode Island $335,724 $4,443,500 $321,756 $11,489,779 $250,000 $76,157 $0 $31,544,904 $30.00 5 South Carolina $968,345 $9,280,935 $380,226 $54,678,305 $300,000 $0 $0 $102,841,783 $21.54 20 South Dakota $167,898 $3,960,564 $236,300 $8,884,996 $0 $0 $0 $23,009,954 $27.23 7 Tennessee $1,255,503 $10,504,074 $288,713 $67,833,134 $0 $0 $0 $108,569,008 $16.71 41 Texas $3,145,884 $35,235,013 $443,685 $343,238,197 $1,135,132 $0 $0 $495,307,760 $18.73 30 Utah $691,817 $6,541,918 $417,354 $23,840,025 $300,000 $41,830 $0 $55,085,814 $18.99 29 Vermont $193,400 $3,831,452 $434,735 $6,435,336 $0 $127,500 $0 $22,190,510 $35.41 2 Virginia $1,482,376 $16,596,540 $6,687,059 $56,964,750 $525,000 $93,440 $305,145 $125,818,443 $15.21 47 Washington $763,305 $12,490,211 $613,406 $77,170,727 $400,000 $192,203 $0 $143,202,309 $20.54 23 West Virginia $708,700 $5,276,327 $482,508 $18,944,386 $0 $100,678 $0 $42,895,510 $23.13 13 Wisconsin $1,457,868 $11,020,471 $458,428 $39,428,145 $0 $76,909 $0 $87,805,919 $15.29 46 Wyoming $162,037 $3,906,477 $396,279 $4,818,164 $151,457 $24,308 $0 $15,600,378 $26.77 8 U.S. TOTAL $69,311,793 $593,902,567 $49,232,988 $3,162,035,045 $18,229,001 $5,257,989 $19,508,812 $5,982,137,418 $18.92 TFAH • healthyamericans.org 9 FEDERAL FUNDING FOR STATES FROM THE HEALTH RESOURCES AND SERVICES ADMINISTRATION (HRSA) HRSA distributes approximately 90 percent of its funding in per capita basis. The bulk of HRSA funds are in its two largest grants to states and territories, public and private healthcare programs, the community and migrant health centers and the providers, health professions training programs and other Ryan White Act HIV programs, and these dollars are awarded organizations. HRSA’s funding is not distributed on a strictly 7 on a competitive basis and/or based on disease burden. FY 2013 HRSA Grants to States by Key Program Area (Selected Programs) HRSA Per Maternal & Child HRSA Total HRSA Per Capita State Primary Health Care Health Professions HIV/AIDS Capita Total Health (All Programs) Ranking (All Programs) Alabama $57,278,771 $20,775,434 $25,929,809 $30,161,232 $136,692,433 $28.28 15 Alaska $41,407,646 $1,113,348 $4,163,826 $2,165,841 $53,010,542 $72.11 1 Arizona $51,287,448 $8,104,416 $21,676,521 $26,136,963 $110,674,542 $16.70 41 Arkansas $34,524,010 $8,253,925 $17,097,012 $10,186,735 $73,241,440 $24.75 19 California $341,649,846 $62,448,175 $71,565,322 $279,886,359 $763,247,514 $19.91 31 Colorado $73,622,136 $11,678,843 $19,315,017 $27,307,207 $136,381,204 $25.89 17 Connecticut $36,602,864 $6,118,212 $17,372,912 $28,166,330 $88,770,706 $24.69 20 Delaware $9,473,617 $3,319,038 $8,534,875 $6,537,572 $28,537,268 $30.83 8 D.C. $13,369,125 $20,455,549 $23,079,540 $61,425,606 $119,802,709 N/A* N/A* Florida $141,436,891 $20,558,562 $41,014,789 $229,702,104 $435,959,358 $22.30 25 Georgia $67,942,177 $13,015,794 $25,484,406 $94,062,051 $204,141,301 $20.43 30 Hawaii $30,594,208 $6,304,681 $6,217,873 $3,944,667 $48,881,830 $34.81 3 Idaho $25,622,940 $1,316,125 $5,086,732 $3,115,878 $36,829,109 $22.84 23 Illinois $124,352,618 $20,920,261 $43,980,766 $84,371,178 $278,664,341 $21.63 28 Indiana $32,381,687 $6,429,127 $27,080,093 $15,980,522 $84,640,691 $12.88 50 Iowa $24,456,635 $2,990,291 $16,587,494 $5,066,097 $53,111,205 $17.19 38 Kansas $22,303,419 $2,994,383 $10,785,066 $4,773,384 $43,697,927 $15.10 46 Kentucky $40,099,915 $4,957,921 $21,983,719 $13,298,858 $85,409,031 $19.43 33 Louisiana $48,761,641 $12,245,542 $25,903,802 $48,441,732 $139,497,464 $30.16 9 Maine $22,751,944 $2,548,445 $12,533,018 $2,768,313 $43,802,200 $32.98 5 Maryland $31,949,997 $11,635,821 $28,932,540 $60,151,913 $134,030,796 $22.61 24 Massachusetts $66,840,339 $31,297,522 $38,605,672 $47,360,657 $185,763,262 $27.76 16 Michigan $68,107,092 $23,008,294 $38,270,764 $30,245,362 $167,062,075 $16.88 40 Minnesota $25,368,965 $8,851,389 $22,110,537 $14,398,969 $77,391,106 $14.28 47 Mississippi $52,372,310 $1,370,050 $12,225,527 $17,608,597 $86,298,258 $28.85 12 Missouri $58,136,573 $17,502,684 $22,439,133 $27,424,077 $132,545,401 $21.93 26 Montana $25,333,859 $3,757,141 $10,229,539 $1,978,737 $45,628,120 $44.95 2 Nebraska $11,827,715 $3,920,412 $9,127,649 $4,222,761 $31,587,889 $16.91 39 Nevada $12,180,092 $1,791,924 $5,989,862 $14,741,176 $36,496,234 $13.08 49 New Hampshire $12,547,784 $1,202,320 $7,609,876 $2,304,380 $25,929,445 $19.59 32 New Jersey $49,207,404 $4,687,966 $26,507,829 $84,298,910 $166,191,807 $18.67 34 New Mexico $48,192,264 $4,414,335 $10,134,040 $5,511,826 $70,466,058 $33.79 4 New York $160,243,332 $32,045,165 $53,829,763 $315,007,625 $565,532,559 $28.78 13 North Carolina $77,996,894 $13,655,527 $27,844,398 $53,610,265 $177,457,921 $18.02 35 North Dakota $4,540,380 $2,619,999 $4,368,358 $683,465 $17,101,493 $23.64 22 Ohio $72,039,766 $37,010,109 $35,529,490 $29,654,894 $178,555,714 $15.43 45 Oklahoma $32,587,516 $5,558,855 $10,203,998 $10,336,017 $60,519,759 $15.72 43 Oregon $56,455,993 $3,105,862 $19,928,412 $12,168,383 $94,749,444 $24.11 21 Pennsylvania $76,511,308 $56,806,363 $48,364,931 $78,628,901 $266,994,770 $20.90 29 Rhode Island $15,897,881 $2,158,457 $9,247,959 $5,325,934 $33,037,101 $31.42 6 South Carolina $59,987,737 $3,263,197 $25,245,443 $31,449,964 $122,272,603 $25.61 18 South Dakota $12,304,871 $2,019,998 $5,667,820 $1,692,499 $24,845,233 $29.41 10 Tennessee $53,279,635 $21,353,775 $25,301,424 $38,713,551 $141,346,550 $21.76 27 Texas $163,132,817 $39,178,099 $57,727,624 $144,593,686 $408,552,115 $15.45 44 Utah $20,829,069 $8,019,546 $13,726,214 $6,490,336 $50,421,687 $17.38 36 Vermont $9,142,755 $2,153,676 $4,757,576 $1,322,496 $18,298,895 $29.20 11 Virginia $54,492,625 $11,125,978 $23,648,880 $41,113,959 $134,552,868 $16.29 42 Washington $78,639,115 $18,067,150 $21,866,385 $76,552,429 $199,363,617 $28.60 14 West Virginia $38,932,091 $3,267,997 $9,350,756 $3,478,840 $58,167,760 $31.37 7 Wisconsin $25,449,976 $13,329,994 $23,614,943 $12,813,403 $78,129,758 $13.61 48 Wyoming $5,533,439 $659,806 $1,896,651 $978,857 $10,124,819 $17.38 36 U.S. TOTAL $2,719,981,132 $625,387,483 $1,099,696,585 $2,152,361,498 $6,764,407,932 $21.40 N/A* *D.C. was not included in the per capita rankings because total funding for D.C. includes funds for a number of national organizations. **The US total reflects HRSA grants to all states and D.C. 10 TFAH • healthyamericans.org WHAT ARE THE FEDERAL GOVERNMENT’S PUBLIC HEALTH OBLIGATIONS? In partnerships with states and to mount an effective response in a localities, the federal government has public health emergency such as a an obligation to: natural disaster, bioterrorism, or an emerging disease; l A ssure the capacity of all levels of government to provide essential pub- l F acilitate the formulation of public lic health services; health goals in collaboration with state and local governments and l A ct when health threats may span many other relevant stakeholders; states, regions, or the whole country; l B e transparent and accountable for l A ct where the solution may be beyond public health investments; and the jurisdiction of individual states; l D isseminate innovation and best prac- l A ct to assist the states when they do tices from state and local public health. not have the expertise or resources Source: Trust for America’s Health. Public Health Leadership Initiative an Action Plan for Healthy People in Healthy Communities in the 21st Century. 8 National Prevention Strategy and Prevention Fund The Affordable Care Act (ACA) included l T he creation of a National Prevention a number of new federally-supported Strategy and Action Plan to find more public health and prevention measures, ways the federal government can sup- aimed at improving the health of port better health across all agencies; Americans, including: l A Prevention and Public Health Fund to l A new focus on cost containment originally provide $12.5 billion in man- and improving health within the datory appropriations over the first 10 healthcare system; years to local communities to improve health and reduce illness rates; and l A major expansion of the number of Americans and types of preventive l N ew community engagement and services covered by insurance; reporting requirements for nonprofit hospitals’ community benefit programs. TFAH • healthyamericans.org 11 THE PREVENTION AND PUBLIC HEALTH FUND Prevention saves lives, reduces healthcare costs and makes the country a healthier, more productive place. More than half of Americans live with at least one serious preventable health condition, like diabetes or heart disease, which forces taxpayers to spend billions of dollars a year on health care. And, today’s children are in danger of becoming the first generation in American history to live shorter, less healthy lives than their parents. The Prevention and Public Health Fund enables communities around the country to invest in proven strategies to improve health. The Fund has the support of more than 800 national, state and local organizations. Combating the leading causes of absenteeism, increasing academic chronic diseases will improve the achievement and improving productivity. health of Americans and reduce Public health emergencies demand healthcare costs over the long term. a public response. The Fund enables The Fund will be used for programs state and local health officials to at the local, state and federal level respond to emergencies that put to reduce the rates of obesity, heart citizens’ lives and health at stake — disease and stroke and tobacco use by including natural disasters, terrorist 5 percent within five years. attacks, infectious diseases, and unsafe Communities across the country food, air and water. The Fund provides often face increased health and training and financial assistance for safety threats without the resources workers, and invests in up-to-date to combat them. The Fund supports equipment and technology, needed community-driven prevention efforts to to protect communities from disease reduce tobacco use, increase physical outbreaks and other health threats. activity, improve nutrition, expand mental Every community has unique challenges. health and injury prevention programs The Fund provides financial support and improve prevention activities. directly to states and communities, and Patients need to be able to act on their gives them flexibility, while holding them doctor’s orders outside of the doctor’s accountable, to address their most office. The Fund supports services and pressing health challenges. programs that improve access to healthy Flexibility must come with accountability choices in our schools, neighborhoods when taxpayer dollars are at stake. and workplaces. The Fund invests in prevention programs Businesses benefit by having a that are proven and effective. Oversight productive, healthy workforce. and evaluation is a key component of Investing in the health of Americans every Fund-sponsored program, and improves the bottom line of businesses strict performance measures ensure by lowering healthcare costs, reducing accountability. 12 TFAH • healthyamericans.org THE NATIONAL PREVENTION, HEALTH PROMOTION, AND PUBLIC HEALTH COUNCIL; THE ADVISORY GROUP ON PREVENTION, HEALTH PROMOTION, AND INTEGRATIVE AND PUBLIC HEALTH AND THE NATIONAL PREVENTION STRATEGY The ACA established a National In June 2011, the Council released and unique department actions being Prevention, Health Promotion, and Public the National Prevention Strategy — a taken to further each of the Strategic Health Council and an Advisory Group guide for the country to achieve, in the Directions and Priorities of the National on Prevention, Health Promotion, and most effective way, improved health and Prevention Strategy. The Council identified Integrative and Public Health, designed well-being. The Strategy identified four three shared commitments across to provide coordination and leadership Strategic Directions: 1) create, sustain the federal government: 1) identifying among 20 executive departments and recognize communities that promote opportunities to consider prevention and agencies at the Federal level health and wellness through prevention; and health; 2) increasing tobacco-free on prevention, wellness and health 2) ensure prevention-focused healthcare environments; and 3) increasing access promotion practices through the public and community prevention efforts to healthy and affordable food. health system. are available, integrated and mutually reinforcing; 3) support people in making Why The National Prevention The Council, chaired by the surgeon healthy choices; and 4) eliminate health Strategy Matters: general, was created by Executive Order disparities to improve the quality of life l N umerous factors outside the in June 2010. for all Americans. healthcare system — including The role of the council is to ensure housing, education, transportation, the It also specified seven evidence-based federal health and prevention efforts are availability of quality affordable foods, priorities: 1) tobacco free living; 2) coordinated, aligned and championed; and conditions in the workplace and preventing drug and excessive alcohol and to encourage partnerships to the environment — often play a large abuse; 3) healthy eating; 4) active living; benefit all Americans among all levels role in public health so working across 5) injury and violence free living; 6) of government, the private sector, agencies to identify and develop reproductive and sexual health; and 7) philanthropic organizations, educational reforms can have a major impact in mental and emotional well-being. organizations and community- and improving the health of all Americans. faith-based organizations. The role In June 2012, the Council released l I f every federal agency focuses of the Advisory Group is to offer the National Prevention Council Action increased attention on prevention and recommendations to the members Plan, which builds from the vision, goal, health promotion, benefits will flow to of the Council and advise them on recommendations, and actions of the the public’s health and will help each effective, evidence-based prevention and landmark National Prevention Strategy. agency fulfill its mission. health-promotion activities. The Action Plan identifies commitments TFAH • healthyamericans.org 13 FOUNDATIONAL CAPABILITIES FOR PUBLIC HEALTH In their April 2012 report, For the Public’s l M obilizing the community and forging l E nsuring sufficient, stable and sustain- Health: Investing in a Healthier Future, partnerships to leverage resources able funding for public health, including the IOM called for increased focus and (funding and otherwise); leveraging resources from non-traditional prioritization among public health agen- sources that also have an interest in l B uilding new models that integrate cies at all levels. They identified a set of improving health, such as across govern- clinical and population health; foundational capabilities that included: 9 ment agencies and from the healthcare l C ultivating leadership — along with sector, private industry, non-profit fund- l I nformation systems and resources; organization, management and raising and community development. l H ealth planning; business — skills needed to build and sustain an effective health department The project stressed that “prioritizing is the l P artnership development and and workforce to effectively and only way to be able to take on new chal- community mobilization; efficiently promote and improve health; lenges in a time of declining resources,” it l P olicy development analysis and is essential to be successful in the future l D emonstrating accountability for what decision support; and that public health should focus on:11 governmental public health does directly l C ommunication; and and for those things that it oversees l E nsuring what is being done is being l P ublic health research, evaluation and through accreditation, continuous quality done well and as efficiently as possible; quality improvement. improvement and transparency; and l C oordinating across all levels of the Following the IOM report, a group of public l P rotecting the public in the event of governmental public health system health thought leaders also participated an emergency or disaster, as well as and other government agencies and in the Transforming Public Health project, responding to day-to-day challenges or jurisdictions to maximize impact; and funded by RWJF and convened by threats, with a cross-trained workforce. l C ultivating and/or training a workforce RESOLVE to develop guidance for public that can deliver foundational capabili- The project also identified a set of addi- health officials and policymakers to ties when implementing programs. tional important issues for public health prioritize vital public health functions in a departments to consider, which include: A subsequent effort, funded by RWJF, shifting political landscape.10 l M aintaining a culture of continuous formed two working groups to define the They summarized the foundational quality improvement; path moving forward that included, 1) capabilities of public health as: the Definitions and Constitution Work- l I mproving coordination across all lev- ing Group, convened under the Public l D eveloping strategies to effectively els of government to foster synergy Health Leadership Forum, managed by promote and improve health; and efficiency; RESOLVE, and 2) the Cost Estimation l U sing integrated data sets for assess- l B uilding a better-and cross-trained Working Group, convened by the Univer- ment, surveillance and evaluation to workforce that is more versatile and sity of Kentucky. The Definitions and identify crucial health challenges, best well equipped to handle a range of Constitution Working Group put together practices and better health; public health needs; a consensus-based report that includes l C ommunicating with the public and other l B olstering research and capitalizing a framework for governmental public audiences to disseminate — and receive on improved technology to access and health services highlighting foundational — information in an effective manner for analyze data to better demonstrate capabilities and foundational areas. health, including health promotion oppor- the value of public health and preven- Below is an overview for a national con- tunities, access to care and prevention; tion services and programs; and ceptual model.12 14 TFAH • healthyamericans.org FOUNDATIONAL CAPABILITIES—CROSS CUTTING SKILLS AND CAPACITIES s ssessment (Surveillance, A l A ccountability, Performance Epidemiology, Laboratory Capacity, Management and Quality and Vital Records) Improvement s ll Hazards Preparedness/Response A l I nformation Technology Services, s Communications including Privacy and Security s olicy Development/Support l H uman Resources Services P s ommunity Partnership Development l F inancial Management, Contract, C and Procurement Services, s rganizational Competencies O including Facilities and Operations l L eadership and Governance l L egal Services and Analysis l H ealth Equity FOUNDATIONAL AREAS—PROGRAMMATIC EXPERTISE AND ACTIVITIES s ommunicable Disease Control C put together by the Definitions and s hronic Disease and Injury Prevention Constitution Working Group to develop C a cost estimation methodology. s nvironmental Public Health E The detailed methodology included s aternal/Child/Family Health M specific details for all steps such as s ccess to/Linkage with Clinical recruitment, data collection method, A instrument piloting and testing and Health Care an implementation timeline. The The second group, the Workgroup methodology provided by the working on Public Health Cost Estimation, group is a first step in the process of developed a methodology for estimating building evidence about the costs of the resources required to develop and public health capabilities and is meant maintain foundational capabilities.13 to be changed and improved after The Public Health Cost Estimation implementation.14 Workgroup used the 11 domains TFAH • healthyamericans.org 15 PUBLIC HEALTH ACCREDITATION The Public Health Accreditation Domain 4: Engage with the community Board (PHAB), created in 2007, has to identify and address health problems. launched a voluntary public health Domain 5: Develop public health poli- accreditation program for state and cies and plans. local public health departments.15 Domain 6: Enforce Public Health Laws. This accreditation process is a major effort to improve and standardize core Domain 7: Promote strategies to im- capabilities of health departments. prove access to healthcare services. The PHAB administers the national public Domain 8: Maintain a competent public health department accreditation program health workforce. for public health departments operated Domain 9: Evaluate and continuously by Tribes, states, local jurisdictions and improve health department processes, territories,16 and in March, 2013, PHAB programs and interventions. announced the first round of public Domain 10: Contribute to and apply the health departments to achieve accredita- evidence base of public health. tion status. PHAB accreditations include domains (groups of standards that Domain 11: Maintain administrative pertain to a broad group of public health and management capacity. services), standards (the required level of Domain 12: Maintain capacity to en- achievement that a health department is gage the public health governing entity. expected to meet) and measures (evalua- Standard 5.4 focuses specifically on tion tools for meeting standards). preparedness and requires that public There are 12 domains. The first 10 do- health departments maintain an all mains address the 10 Essential Public hazards emergency operations plan. In Health Services; domain 11 addresses order to become accredited, a health management and administration, and department must:18 domain 12 addresses governance.17 l P articipate in the process for the devel- The 12 domains include: opment and maintenance of an All Haz- Domain 1: Conduct and disseminate ards Emergency Operations Plan (EOP); assessments focused on population l A dopt and maintain a public health health status and public health issues EOP; and facing the community. l P rovide consultation and/or technical Domain 2: Investigate health problems assistance to Tribal and local health and environmental public health haz- departments in the state regarding ards to protect the community. evidence-based and/or promising Domain 3: Inform and educate about practices/templates in EOP develop- public health issues and function. ment and testing. 16 TFAH • healthyamericans.org B. STATE INVESTMENT IN PUBLIC HEALTH State Public Health Budgets Per Capita State FY 2012-2013 FY 12-13 Per Capita Ranking Hawaii $201,873,600 $144.99 1 New York $2,274,228,415 $116.21 2 Alaska $77,143,500 $105.47 3 District of Columbia $65,973,000 $104.33 4 Idaho $143,214,100 $89.75 5 West Virginia $133,181,354 $71.78 6 North Dakota $46,001,508 $65.75 7 California $2,425,696,000 $63.76 8 Alabama $305,929,969 $63.44 9 Massachusetts $367,338,942 $55.27 10 Wyoming $31,330,064 $54.35 11 Rhode Island $52,987,767 $50.45 12 Arkansas $146,786,093 $49.77 13 New Mexico $97,829,500 $46.91 14 Kentucky $189,192,500 $43.19 15 Tennessee $277,696,100 $43.01 16 Colorado $222,275,563 $42.85 17 Delaware $38,601,500 $42.09 18 Nebraska $72,919,516 $39.30 19 Oklahoma $145,154,000 $38.05 20 Vermont $22,310,357 $35.64 21 Virginia $291,330,197 $35.59 22 Utah $95,652,200 $33.50 23 Washington $207,489,500 $30.08 24 South Dakota $24,180,537 $29.02 25 MEDIAN $27.49 Connecticut $98,689,440 $27.49 26 New Jersey $221,261,000 $24.96 27 Maryland $143,781,785 $24.43 28 Illinois $287,402,900 $22.32 29 Maine $27,046,561 $20.35 30 Montana $19,554,595 $19.45 31 South Carolina $91,847,984 $19.44 32 Texas $503,091,075 $19.31 33 Michigan $186,714,700 $18.89 34 Florida $354,972,558 $18.38 35 Georgia $179,356,456 $18.08 36 Indiana $113,929,495 $17.43 37 Oregon $62,720,932 $16.08 38 Louisiana $73,979,199 $16.08 38 Iowa $48,744,506 $15.86 40 New Hampshire $20,919,806 $15.84 40 Pennsylvania $188,316,000 $14.75 42 Ohio $165,639,694 $14.35 43 Kansas $40,603,359 $14.07 44 Minnesota $71,932,000 $13.37 45 Wisconsin $75,042,700 $13.10 46 North Carolina $121,993,025 $12.51 47 Mississippi $33,117,216 $11.09 48 Nevada $21,657,208 $7.85 49 Arizona $50,003,300 $7.63 50 Missouri $35,292,453 $5.86 51 TFAH • healthyamericans.org 17 Every state allocates and reports its in charge of public health services budget in different ways. States also for FY 2012-13, using a definition as vary widely in the budget details they consistent as possible across all years, provide. This makes comparisons based on how each state reports across states difficult. For this data. TFAH defined “public health analysis, TFAH examined state services” broadly, including most budgets and appropriations bills for state-level health funding. the agency, department, or division WHAT ARE STATE AND LOCAL GOVERNMENTS PUBLIC HEALTH OBLIGATIONS? States and localities have an obligation to: This information should be integrated health at the community level in de- with reporting from local hospitals and signing appropriate programs and l F ulfill core public health functions such healthcare providers to show how well interventions that address key health as diagnosing and investigating health public concerns and health threats problems and improve the health of threats, informing and educating the are being addressed. These reports the region; and public, mobilizing community partner- should also be publicly available and ships, protecting against natural and l D eal with complex, poorly understood utilized by public health departments human-made disasters and enforcing problems by acting as “policy to work collaboratively with hospitals, state health laws; laboratories.” States and localities physicians and others with a role in are closer to the people and to the l P rovide relevant information on the public health to set health goals; problems causing ill health. community’s health and the availability l W ork collaboratively with the multiple of essential public health services.  stakeholders who influence public C. LOCAL INVESTMENT IN PUBLIC HEALTH There are approximately 2,800 local correspondingly, the way resources health departments in the United are determined and allocated differs States serving a diverse assortment significantly. A 2008 study found that of populations ranging from less median local public health spending than 1,000 residents in some rural was $29.57 per capita in 2005, while jurisdictions to around eight million funding ranged from an average of $8 people, as in the case of the New York per person in the lowest 20 percent City Department of Health. 19 Local of communities to nearly $102 per health departments are structured person in the top 20 percent of differently in each state and may be communities.20 A July 2011 study in centralized, decentralized or have a Health Affairs found that increased mixed function. Therefore, the level spending by local public health of responsibility and services provided departments can save lives currently by LHDs varies dramatically, and, lost to preventable illnesses.21 18 TFAH • healthyamericans.org SECTI O N 2: Key Health SECTION 2: KEY HEALTH FACTS Key Health Facts ADULT HEALTH INDICATORS U.S. Total State with State with Facts Highest/Worst Lowest/Best Massachusetts % Uninsured, All Ages (2012) 15.4% Texas (24.6%) (4.1%) AIDS Cumulative Cases Aged 13 and Older (2011 New York North Dakota 1,146,271 Yr End) (202,741) (184) California Alzheimer's Estimated Cases among 65+ (2025) 6,479,700 Alaska (7,700) (660,000) Tennessee % Asthma Prevalence (2010) 13.5% Hawaii (17.6%) (9.3%) California Wyoming Cancer Estimated New Cases - (2013) 1,660,290 (171,330) (2,700) New Chlamydia Rates per 100,000 Population (2012) 456.7 D.C. (1,106.1) Hampshire (233.0) West Virginia Diabetes, % Adults (2012) N/A Alaska (7.0%) (13.0%) Fruits and Vegetables Intake, % who consume fruit West Virginia N/A D.C. (25.6%) and vegetables 5+ times daily (2011) (7.9%) AK, D.C., HI, Human West Nile Virus Cases (as of 12/03/13) 2,318 California (364) ME, WV (0) Alabama Hypertension, % Adults (2011) N/A Utah (22.9%) (40.0%) Louisiana Colorado Obesity, % Adults (2012) N/A (34.7%) (20.5%) Arkansas Physical Inactivity, % Adults (2012) N/A Oregon (16.3%) (31.5%) % Pneumococcal Vaccination Rates 65 and Over New Jersey 68.8% Oregon (76.2%) (2012) (61.6%) % Seasonal Flu Vaccination Rates 65 and Over (2012) 60.1% Nevada (50.5%) Iowa (70.1%) Syphilis Rates per 100,000 Population (2012) 5.0 D.C. (26.7) Montana (0.2) % Tobacco Use - Current Smokers (2012) 19.6% Kentucky (28.3%) Utah (10.7%) California Tuberculosis Number of Cases (2012) 9,945 Wyoming (3) (2,191)  CHILD HEALTH INDICATORS % Uninsured, under 18 (2012) 8.9% Nevada (18.3%) D.C. (2.1%) AIDS Cumulative Cases Under Age 13 New York 9,521 Wyoming (2) (2011 Yr End) (2,457) % Asthma - High School Students (2011) N/A Maryland (28.7%) Iowa (16.0%) Kentucky New York Fruit Indicator – % High School Students (2011) N/A (23.0%) (36.8%) New High School Dropout Rate - % of 9th- to 12th-graders 3.4% Arizona (7.8%) Hampshire who dropped out of public schools (2009-10) (1.2%) Immunization Gap, % of Children Aged 19 to 35 31.6% Alaska (40.5%) Hawaii (19.8%) Months Without All Immunizations (2012) Infant Mortality - Per 1,000 Live Births (2010 Final Mississippi 6.2 Alaska (3.8) Data) (9.7) Mississippi % Low Birthweight Babies (2012 Preliminary Data) 8.0% Alaska (5.6%) (11.6%) Obesity, % High School Students (2011) N/A Alabama (17.0%) Colorado (7.3%) Mississippi Obese, % of 10 to 17 Year Olds (2011) N/A Oregon (9.9%) (21.7%) Pre-Term Births % of live births (2012 Preliminary Mississippi MAY 2014 11.5% Vermont (8.7%) Data) (17.1%) Tobacco: % Current Smokers High School Kentucky N/A Utah (5.9%) Students (2011) (24.1%) % of High School Students who consume West Virginia N/A Indiana (9.0%) recommended levels of vegetables (2011) (18.7%) Sources: CDC. For a detailed list of references see Appendix A. S EC T I ON 3 : Community SECTION 3: COMMUNITY DISEASE AND INJURY PREVENTION PROGRAMS Evidence-Base for Community Prevention Disease and Injury Prevention Programs Programs A series of independent analyses, including those by the IOM and CDC, found that the nation’s public health system had been chronically under-funded for several decades, and the “infrastructure had greatly deteriorated.” The analyses concluded that it would require a long-term, sustained commitment to yield the major improvements required to protect Americans from the range of health threats the country faces in the 21st century.22, 23 In 2008, NYAM and TFAH, in billion annually — across state, consultation with a panel of leading local and federal governments — experts, conducted an analysis that in funding for critical U.S. public found there was a shortfall of $20 health programs.24 MAY 2014 COMPENDIUM OF PROVEN COMMUNITY-BASED PREVENTION PROGRAMS In October 2013, NYAM released A Com- erately or vigorously active, compared to income, uninsured women aged 40 pendium of Proven Community-Based 24 to 38 percent of residents in similar to 64 with chronic disease risk factor Prevention Programs, highlighting 79 neighborhoods without the path. The screenings, lifestyle interventions and evidence-based disease and injury pre- report notes that PACE is an effective referral services. Over the course of a vention programs that have saved lives intervention that demonstrates how year, WISEWOMAN participants improved and improved health.   25 changes to the built environment may their 10-year risk of coronary heart increase neighborhood physical activity. disease by 8.7 percent, and there were The report includes an extensive lit- significant reductions in the percent of erature review, conducted by NYAM, of l N orth Carolina’s State Health Plan for participants who smoked and had high peer reviewed studies that evaluated Teachers and State Employees made blood pressure and high cholesterol. the effectiveness of community-based the Eat Smart, Move More, Weigh Less prevention programs designed to reduce (ESMMWL) guide available to their Asthma: tobacco use, injuries, asthma, alcohol members to better manage weight and l S chool bus emissions collect within abuse and sexually-transmitted infec- reduce associated health care costs. passenger cabins, pollute the environ- tions, increase physical activity and im- The percentage of participants with a ment and contribute disproportionately prove eating habits.  BMI less than 30 increased from 40 to air quality. The Washington State percent to 45 percent and those with Clean School Bus Program found that The Compendium notes that since a normal blood pressure increased school bus retrofits could result in 2008, the number of effective commu- from 23 percent to 32.5 percent. reductions of bronchitis, asthma and nity-based programs and interventions S hape Up Somerville, a comprehensive pneumonia, with conservative benefit– has grown exponentially and the report l effort to prevent obesity in high-risk cost ratios between 7:1 and 16:1. identifies specific programs—that can be taken to scale—which prevent dis- first through third grade students in l U rban, low-income patients with asthma ease and create a healthier population. Somerville, Massachusetts, included from four zip codes were identified improved nutrition in schools, a school through logs of Emergency Department The report includes examples of health curriculum, an after-school (ED) visits or hospitalizations, and of- programs that increase physical activity, curriculum, parent and community fered enhanced care including nurse reduce asthma, sexually transmitted outreach, collaboration with community case management and home visits. infections and tobacco and alcohol restaurants, school nurse education The program provided services to 283 use and prevent violence and injury. and a safe routes to school program children with 39.6 percent Black, 52.3 Summaries of some examples include: (SRTS). After one year, on average, the percent Latino, 72.7 percent using Med- Physical Activity: program reduced one pound of weight icaid and 70.8 percent with a household l he Partnership for an Active Community T gain over eight months for an 8-year- income of less than $25,000. Twelve- Environment (PACE) steering commit- old child. On a population level, this re- month data show a significant decrease tee in New Orleans, Louisiana installed duction in weight gain would translate in any asthma ED visits and hospitaliza- a six-block walking path and school into large numbers of children moving tions and any days of limitation of physi- playground in a low-income Black neigh- out of the overweight category and re- cal activity, patient missed school and borhood. The proportion of residents ducing their risk for chronic diseases. parent missed work. There was a sig- who were active increased significantly l T he Well-Integrated Screening and nificant reduction in hospital costs com- in the neighborhood with the path and Evaluation for Women Across the Nation pared with the comparison community, playground, where 41 percent of those (WISEWOMAN) program provides low- and a return on investment of $1.46. engaging in physical activity were mod- TFAH • healthyamericans.org 21 Violence and Injury Prevention: l T ennessee implemented an extensive about $183 per program participant l T he federal Safe Routes to School statewide sobriety checkpoint program (in 2010 dollars). The study also program allocated funds for state de- (Checkpoint Tennessee). The volume of estimated inpatient savings per par- partments of transportation to build checkpoints increased from about 15 in ticipant of $571, meaning every $1 sidewalks, bicycle lanes, and safe the preceding year to nearly 900 in the in program costs was associated with crossings, improve signage and make program year. The checkpoint activity $3.12 in medical savings, for a $2.12 other improvements that allow chil- was publicized extensively. The program return on investment to the Medicaid dren to travel more safely to school.  resulted in a 20.4 percent reduction in program for every dollar spent. In New York City, from 2001-2010, alcohol related crashes extending at The Compendium is a follow-up to a 2009 annual pedestrian injury rates per least 21 months after conclusion of the report26 released by TFAH and NYAM, 10,000 population were calculated for formal program, preventing nine fatal which followed a 2008 TFAH study27 that different age groups and for census alcohol-related crashes per month. found that an investment of $10 per per- tracts with and without SRTS interven- Tobacco Use: son per year in proven evidenced-based tions during school-travel hours. The community prevention programs that in- l A cost-benefit analysis approach annual rate of school-aged pedes- crease physical activity, improve nutrition was used to estimate the return on trian injury during school-travel hours and prevent smoking and other tobacco investment for the tobacco cessation decreased 44 percent in census tracts use could save the country more than program implemented by the state of with SRTS interventions. $16 billion annually within five years—a Massachusetts. Administrative data indicated that program costs were return of $5.60 for every $1. COMMUNITY GUIDE TO PREVENTIVE SERVICES CDC publishes The Community Guide and local health departments, other to Preventive Services, featuring a 28 government agencies, communities, collection of all of the Community healthcare providers, employers, schools Preventive Services Task Force findings and research organizations. and the systematic reviews on which The Community Guide includes a review they are based. The Task Force was of the evidence for which community established in 1996 by the U.S. health interventions have worked or have Department of Health and Human not; in which populations and setting Services (HHS) to identify population an intervention worked or not; what an health interventions that are scientifically intervention may cost and what are the proven to save lives, increase lifespans expected returns for an investment; and and improve quality of life. The Task what interventions need more research Force produces recommendations (and before it is known if they will work or not. identifies evidence gaps) to help inform the decision making of federal, state, 22 TFAH • healthyamericans.org SECTI O N 4: Recommendations SECTION 4: RECOMMENDATIONS Recommendations America’s future economic well-being is inextricably tied to our health. High rates of preventable diseases are one of the biggest drivers of healthcare costs in the country. And, right now, Americans are not as healthy and productive as they could or should be to compete in the global economy. The nation’s public health system is Public Health Fund is used to build responsible for keeping Americans upon and expand — not supplant healthy and safe. Public health is — existing efforts. The Prevention devoted to preventing disease and Fund is the nation’s largest single injury. If we kept Americans healthier, investment in prevention, using we could significantly drive down trips evidence-based and innovative to the doctor’s office or emergency partnership approaches to improve room, reduce healthcare costs and the health of Americans. Without improve productivity. a strong investment in prevention, we will never advance in the fight In addition to shoring up the core to prevent diseases, curb the obesity ongoing funds for public health, we epidemic or reduce smoking rates. need to ensure the Prevention and MAY 2014 TFAH recommends that: l C ore funding for public health — at should be tied to achieving and the federal, state and local levels — maintaining these capabilities. be increased; The public deserves to know how effectively their tax dollars are l F unding be considered strategically being used, and accreditation, — so funds are used efficiently to continuous quality improvement maximize effectiveness in lowering and transparency are important disease rates and improving health; ways to help demonstrate that these l I n addition to reducing rates of capabilities are being met. The chronic disease, the Prevention U.S. Department of Health and Fund be targeted to help modernize Human Services’ Advisory Group the nation’s approach to public on Prevention has recommended health; that “federal funds be made available to help state and local l A ccountability must be at the health departments to build the cornerstone of public health foundational capabilities that are funding — the use of funds needed to support accreditation and should be transparent and clearly a response to 21st century health communicated with the public; and challenges.” Federal resources, l A ll Americans should be protected such as those available through the by a set of foundational public Preventive Services Block Grant, health capabilities and services no which was doubled in the FY 2014 matter where they live. For this to appropriations, could provide the be accomplished, these capabilities Program an opportunity to address must be fully funded, and funding these needs. 24 TFAH • healthyamericans.org APPEN DI C ES : Appendix A APPENDIX A: DATA AND METHODOLOGY Notes on Data and Methodology The sources for the funds and indicators come from a variety of publicly available sources. In some cases fiscal years for funding may vary depending on availability of data, and year of health indicators may vary slightly as well. Funding References CDC Funds for State and Local Bureau population estimates. HRSA Health Departments, Universities, & Per Capita Ranking based on TFAH Other Public and Private Agencies calculated per capita totals. FY 2013 data were all provided by the ASPR Hospital Preparedness Program U.S. Centers for Disease Control and FY 2013 funding from U.S. Department Prevention’s Financial Management of Health and Human Services: Office. The total (all categories) was Office of the Assistant Secretary for also provided by the CDC; it includes Preparedness and Response Office program areas not highlighted of Preparedness and Emergency here. CDC Per Capita Total FY 2012 Operations Division of National calculated by TFAH by dividing CDC Healthcare Preparedness Programs. provided total by July 1, 2013 U.S. “Hospital Preparedness Program (HPP) Census Bureau population estimates. Budget Period 2 (Fiscal Year 2013) CDC Per Capita Ranking based on Funding” (accessed January 2, 2014). TFAH calculated per capita totals. State Public Health Budget HRSA Health Professions, HIV/ Methodology TFAH conducted an AIDS, Maternal & Child Health, and analysis of state spending on public Primary Health Care FY 2013 funding health for the last budget cycle, fiscal data come from HRSA’s Geospatial year 2012-2013. For those states that Data Warehouse, State Profile Report only report their budgets in biennium (accessed January 2013.) The total cycles, the 2013-2015 period (or the HRSA dollar amount also came from 2012-2014 and 2012-2013 for Virginia this source. HRSA key program area and Wyoming respectively) was used, totals, however, were calculated by and the percent change was calculated TFAH using Microsoft Excel. HRSA from the last biennium, 2011-2013 (or Per Capita Total FY 2013 calculated 2010-2012 and 2011-2012 for Virginia by TFAH by dividing HRSA Total and Wyoming respectively). MAY 2014 dollars by July 1, 2013 U.S. Census This analysis was conducted from August Because each state allocates and Population Facts to October of 2013 using publicly reports its budget in a unique way, U.S. Total Population estimates available budget documents through comparisons across states are difficult. come from the U.S. Census Bureau state government web sites. Based This methodology may include 2013, National and State Population on what was made publicly available, programs that, in some cases, the state Estimates, Resident Population Data, budget documents used included may consider a public health function, released December 2013 (accessed either executive budget document that but the methodology used was selected January 3, 2014). listed actual expenditures, estimated to maximize the ability to be consistent expenditures, or final appropriations; across states. As a result, there may be Poverty Rate 2011-2012 (2-Year appropriations bills enacted by the programs or items states may wish to Average) estimates from the state’s legislature; or documents from be considered “public health” that may U.S. Census Bureau 2011-2012, legislative analysis offices. not be included in order to maintain Percentage of People in Poverty by the comparative value of the data. State Using 2- and 3- year Averages: “Public health” is defined to broadly 2009-2010 and 2011-2012 (accessed include all health spending with the Finally, to improve the comparability December 19, 2013). exception of Medicaid, Children's of the budget data between FY 2011- Health Insurance Program, or 2012 and FY 2012-2013 (or between Total Number of U.S. Uninsured, All comparable health coverage programs biennium), TFAH adjusted the FY Ages estimates come from the U.S. for low-income residents. Federal 2012-2013 numbers for inflation Census Bureau, Current Population funds, mental health funds, addiction (using a 0.9817 conversion factor Survey, Table HI06, Health Insurance or substance abuse-related funds, based on the U.S. Dept. of Labor Coverage Status by State for All People: Women, Infants and Children funds, Bureau of Labor Statistics; Consumer 2012 (accessed December 17, 2013). services related to developmental Price Index Inflation Calculator at Total Number of Uninsured, under18 disabilities or severely disabled persons, http://www.bls.gov/cpi/).   estimates come from the U.S. Census and state-sponsored pharmaceutical After compiling the results from Bureau. Current Population Survey, programs also were not included this online review of state budget Table HI05: Health Insurance in order to make the state-by-state documents, TFAH coordinated with Coverage Status and Type of Coverage comparison more accurate since the Association of State and Territorial by State and Age for All People: 2012 many states receive federal money for Health Officials to confirm the findings (December 18, 2013). these particular programs. In a few with each state health official.  ASTHO cases, state budget documents did not sent out emails on October 24, 2013 Adult Health Indicator allow these programs, or other similar and state health officials were asked to References human services, to be disaggregated; confirm or correct the data with TFAH Adult Physical Inactivity Rate 2012 these exceptions are noted. For most staff by November 8, 2013.  ASTHO data come from the Behavioral Risk states, all state funding, regardless of followed up via email with those state Factor Surveillance System (BRFSS) general revenue or other state funds health officials who did not respond Prevalence Data 2012, percent respond- (e.g. dedicated revenue, fee revenue, by the November 8, 2013 deadline.  In ing “did not engage in any physical etc.), was used. In some cases, only the end, six states did not respond by activity”. National Center for Chronic general revenue funds were used in December 3, 2013 when the report went Disease Prevention & Health Promo- order to separate out federal funds; to print.  These states were assumed to tion, Centers for Disease Control and these exceptions are also noted. be in accordance with the findings.  Prevention. Available at BRFSS Data. 26 TFAH • healthyamericans.org AIDS Cumulative Cases Aged 13 and Disease Control and Prevention Sexually Obesity was defined as having a BMI Older 2011 Yr End data come from the Transmitted Disease Surveillance, 2012 greater than or equal to 30. U.S. Centers for Disease Control and (accessed January 8, 2014). Pneumococcal Vaccination Rates Prevention, National Center for HIV, Diabetes 2012 data come from the 65 and Over 2012 data come from STD, and Tuberculosis (TB) Preven- BRFSS Prevalence Data 2012, percent the BRFSS Prevalence Data 2012.  tion, Table 20, HIV Surveillance Report: responding “ever been told” they National Center for Chronic Disease AIDS diagnoses, by area of residence, have diabetes. National Center for Prevention & Health Promotion, 2011 and cumulative—United States Chronic Disease Prevention & Health Centers for Disease Control and (accessed December 18, 2013). Promotion, Centers for Disease Prevention.  Available at BRFSS Data. Alzheimer’s Estimated Cases among Control and Prevention. Available at Seasonal Flu Vaccination Rates 65 65+ (2025) data come from the BRFSS Data. and Over 2012 data come from Alzheimer’s Association report Fruit and Vegetable Intake 2011 data the BRFSS Prevalence Data 2012.  Alzheimer’s Disease Facts and Figures come from the BRFSS Prevalence National Center for Chronic Disease 2013 (December 19, 2013). Data 2011, percent who consume Prevention & Health Promotion, Asthma 2010 data come from the fruit and vegetables 5+ times daily.  Centers for Disease Control and BRFSS Prevalence Data 2010, percent Available at BRFSS Data. Prevention.  Available at BRFSS Data. responding “ever been told” they Human West Nile Virus Cases 2013 Syphilis Rates per 100,000 Population have asthma. National Center for data come from the 2013 West Nile (2012) data come from the Division Chronic Disease Prevention & Health Virus Human Infections in the United of STD Prevention, National Center Promotion, Centers for Disease States (accessed December 19, 2013). for HIV/AIDS, Viral Hepatitis, STD, Control and Prevention.  Available at and TB Prevention, U.S. Centers BRFSS Data. Hypertension 2011 data come from for Disease Control and Prevention the BRFSS Prevalence Data 2011, Breast Feeding Report Card 2010 Sexually Transmitted Disease percent responding “ever been data come from “Breastfeeding Surveillance, 2012 (accessed January told” they have high blood pressure. Report Card, United States: 8, 2014). Hypertension data is collected only on Outcome Indicators.” CDC National odd-numbered years. National Center Tobacco Use — Current Smokers Immunization Survey, Provisional for Chronic Disease Prevention 2012 data come from the BRFSS Data, 2010 births  (accessed & Health Promotion, Centers for Prevalence Data 2012, percent December 19, 2013). Disease Control and Prevention. responding they are current smokers. Cancer Estimated New Cases 2013 Available at BRFSS Data. National Center for Chronic Disease data come from the American Cancer Prevention & Health Promotion, Obesity 2012 data were calculated Society’s Cancer Facts and Figures Centers for Disease Control and by contractors using self-reported 2013 (accessed December 19, 2013). Prevention. Available at BRFSS Data. height and weight measure from Chlamydia Rates per 100,000 Population the BRFSS Prevalence Data 2012. Tuberculosis Number of Cases 2012 (2012) data come from the Division National Center for Chronic Disease data come from “Reported Tubercu- of STD Prevention, National Center Prevention & Health Promotion, losis in the United States, 2012,” U.S. for HIV/AIDS, Viral Hepatitis, STD, Centers for Disease Control and Centers for Disease Control and Pre- and TB Prevention, U.S. Centers for Prevention. Available at BRFSS Data. vention (accessed December 20, 2013). TFAH • healthyamericans.org 27 Child and Adolescent Health Facts AIDS Cumulative Cases Children Data—School Year 2009-2010. Table 4: Under 13 2011 Yr End data Public high school number of dropouts, come from the U.S. Centers for event dropout rate, and enrollment Disease Control and Prevention, for grades 9-12, by state or jurisdiction: National Center for HIV, STD, School year 2009-2010. National and TB Prevention, Table 20, HIV Center for Education Statistics, U.S. Surveillance Report: AIDS diagnoses, Department of Education (accessed by area of residence, 2011 and February 20, 2014). cumulative—United States (accessed Immunization Gap: Children December 18, 2013). Aged 19 to 35 Months without All Asthma 2011 High School Students data Immunizations 2012 data come from come from the Youth Risk Behavior Estimated Vaccination Coverage with Surveillance System, Comprehensive Individual Vaccines and Selected Results 2011, percent responding “ever Vaccination Series Among Children been told” they have asthma. National 19-35 Months of Age by State and Local Center for Chronic Disease Prevention Area U.S., National Immunization & Health Promotion, Centers for Survey, 2012 (accessed December 18, Disease Control and Prevention. 2013). TFAH used the data for the Available at: http://www.cdc.gov/ 4:3:1:3:3:1:4 series which is the CDC- mmwr/pdf/ss/ss6104.pdf (accessed recommended series for children aged January 14, 2013). 19--35 months. The 4:3:1:3:3:1:4 series is used to evaluate progress toward one Fruit and Vegetable Behavioral of the Healthy People 2020 objectives, Indicators Students data come from which aims to achieve greater than the Youth Risk Behavior Surveillance 80% coverage with the series among System, Comprehensive Results 2011, children ages 19--35 months. percent responding “ate fruit or drank 100% fruit juices two or more times/ Infant Mortality per 1,000 Live Births day” and “ate vegetables three or more 2010 data come from the National times/day” in the past seven days. Center for Health Statistics, National National Center for Chronic Disease Vital Statistics Report, Deaths: Final Data Prevention & Health Promotion, for 2010 (accessed December 23, 2013). Centers for Disease Control and Low Birthweight Babies 2012 data Prevention. Available at: http://www. come from the National Center cdc.gov/mmwr/pdf/ss/ss6104.pdf for Health Statistics, National Vital (accessed January 14, 2013). Statistics Report, Births: Preliminary High School Dropout Rates data come Data for 2012, State-specific Detailed from Public School Graduates and Tables for 2012, Table I-4 (accessed Dropouts from the Common Core of December 23, 2013). 28 TFAH • healthyamericans.org Obese High School Students 2011 Pre-Term Births as Percent of Live data come from the Youth Risk Births 2012 data come from the Behavior Surveillance System, National Center for Health Statistics, Comprehensive Results 2011. National Vital Statistics Report, Births: National Center for Chronic Disease Preliminary Data for 2012, Table I-3 Prevention & Health Promotion, (accessed December 23, 2013). Centers for Disease Control and Tobacco: Current Smokers High Prevention. Available at http://www. School Students 2011 data come from cdc.gov/mmwr/pdf/ss/ss6104.pdf. the Youth Risk Behavior Surveillance Obese 10 to 17 Year Olds 2011 data System, Comprehensive Results 2011, come from the National Survey of percent of “students who smoked Children’s Health, 2011. Child and cigarettes on one or more of the Adolescent Health Measurement past 30 days.” National Center for Initiative. 2011 National Survey of Chronic Disease Prevention & Health Children’s Health, Data Resource Promotion, Centers for Disease Center for Child and Adolescent Control and Prevention. Available Health website.  Available at http:// at http://www.cdc.gov/mmwr/pdf/ childhealthdata.org/browse/ ss/ss6104.pdf (accessed January 14, survey?q=2456&r=1 (accessed 2013). December 17, 2013). Other Public Health Indicators Health Professions Shortage Areas: Center for Health Workforce Analysis Primary Care, Mental Health, Dental in the Bureau of Health Professions, Care FY 2013 data come from HRSA’s Health Resources and Services Geospatial Data Warehouse, State Profile Administration paper “What Is Behind Report (accessed January 2, 2013). HRSA’s Projected Supply, Demand and Shortage of Registered Nurses?” Projected Supply vs. Demand for RNs Washington, D.C.: September 2004. (2010) data comes from the National TFAH • healthyamericans.org 29 APPENDIX B: STATE-BY-STATE ADULT HEALTH INDICATORS Adult Health Indicators AIDS Percent Adult Physical Chlamydia Cumulative Alzheimer's Exclusive Cancer Diabetes 2012 2013 Census % Uninsured, Inactivity Rate Asthma Rates per Cases Aged Estimated Breastfeeding Estimated Percentage State Population All Ages 2012 Prevalence 100,000 13 and Cases among at 6 Months New Cases – (95% Conf Estimates (2012) (95% Conf 2010 Population Older – 2011 65+ (2025) – from Births 2013 Interval) Interval) (2012) Yr End 2010^ Alabama 4,833,722 14.8 27.2% (+/- 1.4) 10,519 110,000 11.8% 11.9% 27,080 637.6 12.3% (+/- 0.9) Alaska 735,132 19 18.5% (+/- 1.6) 786 7,700 14.4% 26.8% 3,290 755.8 7.0% (+/- 1.0) Arizona 6,626,624 18 22.6% (+/- 1.6) 13,026 130,000 14.8% 15.0% 34,010 469.6 10.6% (+/- 1.2) Arkansas 2,959,373 18.4 31.5% (+/- 1.8) 4,688 76,000 13.6% 9.2% 16,330 565.4 11.3% (+/- 1.0) California 38,332,521 17.9 19.2% (+/- 1.0) 167,986 660,000 12.6% 27.4% 171,330 444.9 9.8% (+/- 0.7) Colorado 5,268,367 13.7 17.0% (+/- 1.0) 10,348 110,000 14.7% 24.7% 23,410 422.7 7.4% (+/- 0.6) Connecticut 3,596,080 8.1 22.1% (+/- 1.3) 16,522 76,000 15.3% 15.5% 21,180 364.9 9.2% (+/- 0.8) Delaware 925,749 10.8 23.5% (+/- 1.6) 4,310 16,000 15.1% 17.4% 5,370 489.2 9.6% (+/- 1.0) D.C. 646,449 7.9 17.4% (+/- 1.8) 21,238 10,000 15.5% 14.6% 2,920 1,101.6 8.2% (+/- 1.2) Florida 19,552,860 21.5 23.3% (+/- 1.5) 125,268 590,000 13.8% 10.6% 118,320 407.4 11.4% (+/- 1.1) Georgia 9,992,167 19.2 23.6% (+/- 1.5) 41,814 160,000 11.5% 6.2% 49,280 534.0 9.9% (+/- 0.9) Hawaii 1,404,054 7.7 18.7% (+/- 1.4) 3,391 34,000 17.6% 22.0% 6,650 461.2 7.8% (+/- 1.0) Idaho 1,612,136 15.9 20.3% (+/- 1.8) 773 38,000 13.6% 27.0% 7,670 287.1 8.5% (+/- 1.0) Illinois 12,882,135 13.6 21.8% (+/- 1.6) 40,531 240,000 13.6% 11.1% 66,090 526.1 9.4% (+/- 1.0) Indiana 6,570,902 13.4 25.9% (+/- 1.2) 10,080 130,000 14.2% 13.8% 35,550 452.7 10.9% (+/- 0.8) Iowa 3,090,416 10.1 23.1% (+/- 1.2) 2,163 77,000 11.6% 18.8% 17,480 371.5 9.7% (+/- 0.7) Kansas 2,893,957 12.6 22.9% (+/- 1.0) 3,424 62,000 13.2% 15.1% 14,370 387.8 9.4% (+/- 0.6) Kentucky 4,395,295 15.7 29.7% (+/- 1.3) 5,828 97,000 14.9% 14.4% 25,100 395.3 10.7% (+/- 0.8) Louisiana 4,625,470 18.3 29.9% (+/- 1.5) 22,104 100,000 11.6% 10.7% 24,930 597.9 12.3% (+/- 1.0) Maine 1,328,302 9.5 20.9% (+/- 1.0) 1,309 28,000 15.7% 22.9% 9,190 257.0 9.7% (+/- 0.7) Maryland 5,928,814 12.4 23.1% (+/- 1.3) 38,073 100,000 12.4% 15.1% 30,680 455.3 10.2% (+/- 1.0) Massachusetts 6,692,824 4.1 19.8% (+/- 0.8) 23,392 140,000 15.3% 20.6% 38,250 357.5 8.3% (+/- 0.5) Michigan 9,895,622 10.9 23.3% (+/- 1.2) 17,939 190,000 15.8% 13.0% 57,560 481.6 10.5% (+/- 0.8) Minnesota 5,420,380 8.3 17.6% (+/- 0.9) 6,040 110,000 10.9% 23.5% 28,410 337.8 7.3% (+/- 0.6) Mississippi 2,991,207 15.3 30.8% (+/- 1.5) 8,481 65,000 11.6% 5.1% 15,830 774.0 12.5% (+/- 0.9) Missouri 6,044,171 13.3 24.7% (+/- 1.5) 13,275 130,000 14.2% 15.7% 33,950 463.1 10.7% (+/- 1.0) Montana 1,015,165 18.1 20.5% (+/- 1.1) 507 29,000 12.9% 20.1% 5,450 383.4 7.2% (+/- 0.6) Nebraska 1,868,516 13.3 21.0% (+/- 0.8) 1,857 44,000 12.2% 21.4% 9,060 366.2 8.1% (+/- 0.5) Nevada 2,790,136 23.5 21.3% (+/- 1.7) 7,170 42,000 14.5% 18.6% 13,830 408.9 8.9% (+/- 1.2) New Hampshire 1,323,459 12 20.0% (+/- 1.3) 1,278 26,000 15.0% 24.9% 8,470 233.0 9.1% (+/- 0.8) New Jersey 8,899,339 14 24.9% (+/- 1.0) 56,154 170,000 13.3% 10.9% 49,440 309.2 9.3% (+/- 0.6) New Mexico 2,085,287 21.9 21.8% (+/- 1.1) 3,259 43,000 14.6% 19.3% 10,090 571.4 10.3% (+/- 0.7) New York 19,651,127 11.3 24.7% (+/- 1.6) 202,741 350,000 14.7% 16.5% 108,760 516.5 9.7% (+/- 1.1) North Carolina 9,848,060 17.2 24.9% (+/- 1.0) 21,288 210,000 12.6% 14.8% 53,200 524.0 10.4% (+/- 0.7) North Dakota 723,393 11.5 23.8% (+/- 1.6) 184 20,000 10.6% 20.5% 3,510 425.2 8.6% (+/- 0.9) Ohio 11,570,808 12.3 25.3% (+/- 1.0) 18,678 250,000 13.8% 17.7% 66,610 460.3 11.7% (+/- 0.7) Oklahoma 3,850,568 17.2 28.3% (+/- 1.3) 5,810 96,000 14.2% 16.6% 20,160 444.2 11.5% (+/- 0.8) Oregon 3,930,065 15.4 16.3% (+/- 1.3) 7,122 110,000 16.2% 23.9% 21,720 347.5 9.9% (+/- 1.0) Pennsylvania 12,773,801 12 23.5% (+/ 0.9) 40,179 280,000 13.8% 16.5% 79,560 431.6 10.2% (+/- 0.6) Rhode Island 1,051,511 12.3 23.6% (+/- 1.5) 3,027 24,000 16.7% 16.7% 6,280 410.3 9.8% (+/- 1.0) South Carolina 4,774,839 14.3 25.1% (+/- 1.1) 16,905 100,000 12.9% 16.0% 27,620 580.2 11.6% (+/- 0.8) South Dakota 844,877 14.4 22.5% (+/- 1.5) 346 21,000 11.6% 26.3% 4,570 476.2 7.8% (+/- 0.9) Tennessee 6,495,978 13.9 28.6% (+/- 1.5) 15,606 140,000 9.3% 4.1% 36,580 507.9 11.9% (+/- 1.0) Texas 26,448,193 24.6 27.2% (+/- 1.3) 85,710 470,000 12.8% 14.5% 112,230 494.8 10.6% (+/- 0.8) Utah 2,900,872 14.4 16.6% (+/- 0.9) 2,670 50,000 14.3% 22.5% 10,810 270.3 7.2% (+/- 0.5) Vermont 626,630 7 17.2% (+/- 1.2) 524 13,000 17.2% 25.9% 4,200 275.2 7.3% (+/- 0.8) Virginia 8,260,405 12.5 22.5% (+/- 1.3) 20,522 160,000 12.9% 15.1% 40,870 431.8 10.6% (+/- 0.8) Washington 6,971,406 13.6 19.0% (+/- 0.9) 13,762 150,000 15.8% 19.6% 37,290 360.1 8.8% (+/- 0.9) West Virginia 1,854,304 14.6 31.0% (+/- 1.5) 1,898 50,000 10.7% 9.1% 11,450 258.2 13.0% (+/- 1.0) Wisconsin 5,742,713 9.7 20.4% (+/- 1.6) 5,463 130,000 12.8% 15.3% 31,590 415.4 8.3% (+/- 1.0) Wyoming 582,658 15.4 21.1% (+/- 1.6) 305 15,000 14.7% 24.9% 2,700 370.0 9.1% (+/- 1.0) U.S. Total 316,128,839 15.4 N/A 1,146,271 6,479,700 13.5% 16.4% 1,660,290 456.7 N/A Notes ^The AAP Section on Breastfeeding, American Academy of Family Physicians, World Health Organization, United Nations Children’s Fund, and many other health organizations recommend exclusive breastfeeding for the first 6 months of life. 30 TFAH • healthyamericans.org Fruits and Human Seasonal Syphilis Tobacco Vegetables West Nile Hypertension Pneumococcal Poverty Flu Obesity 2012 Rates per Use – Tuberculosis (5 or more Virus Cases 2011 Vaccination 2011-2012 Vaccination State Percentage 100,000 Current Number of times a day) 2013 (as of (95% Conf Rates 65 and (2-Year Rates 65 (95% Conf Interval) Population Smokers Cases – 2012 2011 (95% Conf December 3, Interval) Over 2012 Average) and Over (2012) 2012 Interval) 2013) 2012 Alabama 12.5% (+/- 1.1) 7 40.0% (+/- 1.6) 33.0% (+/- 1.5) 67.1% 15.8% 61.2% 4.5 23.8% 134 Alaska 18.9% (+/- 1.9) 0 29.4% (+/- 2.1) 25.7% (+/- 1.8) 62.5% 10.8% 50.8% 1.5 20.5% 66 Arizona 21.4% (+/- 2.0) 33 28.0% (+/- 2.0) 26.0% (+/- 1.8) 66.2% 18.1% 52.3% 3.1 17.1% 211 Arkansas 13.5% (+/- 1.7) 18 35.7% (+/- 2.1) 34.5% (+/- 1.9) 63.5% 19.4% 57.2% 5.9 25.0% 70 California 24.4% (+/- 0.9) 364 27.8% (+/- 0.9) 25.0% (+/- 1.1) 67.5% 16.4% 57.9% 7.8 12.6% 2,191 Colorado 19.0% (+/- 1.0) 316 24.9% (+/- 1.0) 20.5% (+/- 1.0) 73.8% 12.5% 66.2% 4.1 17.7% 64 Connecticut 20.8% (+/- 1.4) 4 29.7% (+/- 1.5) 25.6% (+/- 1.3) 67.6% 10.2% 59.5% 1.5 16.0% 74 Delaware 12.9% (+/- 1.4) 3 34.6% (+/- 1.9) 26.9% (+/- 1.7) 70.7% 13.6% 63.1% 4.2 19.7% 28 D.C. 25.6% (+/- 2.1) 0 29.9% (+/- 2.0) 21.9% (+/- 2.1) 64.0% 19.1% 56.7% 26.7 19.6% 37 Florida 18.4% (+/- 1.1) 4 34.2% (+/- 1.3) 25.2% (+/- 1.6) 65.8% 15.1% 54.7% 7.2 17.7% 679 Georgia 15.4% (+/- 1.1) 6 32.3% (+/- 1.3) 29.1% (+/- 1.7) 66.2% 18.3% 60.1% 9.5 20.4% 357 Hawaii 19.7% (+/- 1.4) 0 28.7% (+/- 1.5) 23.6% (+/- 1.6) 65.1% 13.0% 62.7% 1.7 14.6% 117 Idaho 17.4% (+/- 1.5) 40 29.4% (+/- 1.7) 26.8% (+/- 2.0) 68.5% 15.1% 52.0% 1.6 16.4% 15 Illinois 18.3% (+/- 1.6) 112 31.0% (+/- 1.8) 28.1% (+/- 1.7) 63.7% 13.4% 52.5% 6.2 18.6% 347 Indiana 15.0% (+/- 1.1) 21 32.7% (+/- 1.3) 31.4% (+/- 1.3) 68.0% 15.4% 57.1% 3.4 24.0% 102 Iowa 13.5% (+/- 1.0) 42 29.9% (+/- 1.3) 30.4% (+/- 1.4) 70.8% 10.4% 70.1% 2.3 18.1% 46 Kansas 13.3% (+/- 0.6) 78 30.8% (+/- 0.8) 29.9% (+/- 1.2) 70.3% 14.2% 66.7% 0.8 19.4% 42 Kentucky 10.6% (+/- 1.0) 3 37.9% (+/- 1.5) 31.3% (+/- 1.4) 65.6% 16.9% 61.8% 3.4 28.3% 80 Louisiana 8.2% (+/- 0.9) 54 38.3% (+/- 1.4) 34.7% (+/- 1.6) 67.7% 21.1% 63.8% 7.4 24.8% 149 Maine 19.5% (+/- 0.9) 0 32.2% (+/- 1.0) 28.4% (+/- 1.2) 70.7% 13.1% 61.3% 1.3 20.3% 17 Maryland 16.6% (+/- 1.2) 16 31.3% (+/- 1.4) 27.6% (+/- 1.3) 67.4% 9.6% 63.2% 7.4 16.2% 224 Massachusetts 18.8% (+/- 0.9) 8 29.2% (+/- 1.0) 22.9% (+/- 0.9) 70.2% 10.9% 63.6% 4.8 16.4% 215 Michigan 17.8% (+/- 1.1) 36 34.2% (+/- 1.3) 31.1% (+/- 1.3) 66.8% 14.3% 55.4% 3.0 23.3% 149 Minnesota 15.2% (+/- 0.8) 79 26.3% (+/- 1.0) 25.7% (+/- 1.1) 73.6% 10.0% 65.5% 2.2 18.8% 162 Mississippi 10.3% (+/- 0.9) 45 39.2% (+/- 1.4) 34.6% (+/- 1.6) 65.8% 19.7% 62.4% 5.0 24.0% 81 Missouri 14.2% (+/- 1.3) 26 34.3% (+/- 1.6) 29.6% (+/- 1.6) 71.1% 15.3% 67.3% 2.6 23.9% 89 Montana 16.0% (+/- 1.1) 38 30.1% (+/- 1.3) 24.3% (+/- 1.2) 69.5% 15.0% 57.5% 0.2 19.7% 5 Nebraska 14.6% (+/- 0.7) 216 28.5% (+/- 0.8) 28.6% (+/- 0.9) 70.0% 11.2% 62.9% 0.4 19.7% 22 Nevada 18.7% (+/- 2.0) 11 30.9% (+/- 2.2) 26.2% (+/- 1.9) 64.1% 15.6% 50.0% 4.1 18.1% 82 New Hampshire 22.5% (+/- 1.5) 1 30.6% (+/- 1.5) 27.3% (+/- 1.5) 75.0% 7.9% 58.9% 2.7 17.2% 9 New Jersey 16.6% (+/- 0.9) 11 30.6% (+/- 1.1) 24.6% (+/- 1.0) 61.6 10.4% 61.2% 2.6 17.3% 302 New Mexico 18.8% (+/- 1.1) 38 28.5% (+/- 1.2) 27.1% (+/- 1.2) 70.8% 21.3% 57.8% 4.9 19.3% 40 New York 19.9% (+/- 1.3) 26 30.6% (+/- 1.4) 23.6% (+/- 1.5) 67.1% 16.6% 55.1% 6.3 16.2% 866 North Carolina 14.1% (+/- 1.0) 3 32.4% (+/- 1.3) 29.6% (+/- 1.1) 70.2% 16.3% 68.4% 3.6 20.9% 211 North Dakota 13.7% (+/- 1.2) 123 28.9% (+/- 1.5) 29.7% (+/- 1.8) 68.8% 10.7% 59.7% 0.6 21.2% 26 Ohio 14.6% (+/- 1.0) 24 32.7% (+/- 1.3) 30.1% (+/- 1.1) 69.5% 15.2% 61.0% 3.7 23.3% 149 Oklahoma 9.8% (+/- 0.9) 78 35.5% (+/- 1.4) 32.2% (+/- 1.4) 74.9% 16.0% 67.8% 2.2 23.3% 88 Oregon 22.3% (+/- 1.4) 1 29.8% (+/- 1.5) 27.3% (+/- 1.7) 76.2% 13.9% 53.9% 5.5 17.9% 61 Pennsylvania 16.4% (+/- 1.0) 11 31.4% (+/- 1.2) 29.1% (+/- 1.0) 71.1% 13.2% 60.2% 3.9 21.4% 234 Rhode Island 19.8% (+/- 1.4) 1 33.0% (+/- 1.5) 25.7% (+/- 1.6) 71.4% 13.5% 57.6% 4.2 17.4% 23 South Carolina 12.5% (+/- 0.9) 7 36.4% (+/- 1.3) 31.6% (+/- 1.2) 69.4% 17.8% 60.1% 4.8 22.5% 122 South Dakota 11.0% (+/- 1.2) 148 30.9% (+/- 1.9) 28.1% (+/- 1.6) 64.1% 13.7% 66.4% 2.2 22.0% 19 Tennessee 10.6% (+/- 1.9) 23 38.6% (+/- 2.6) 31.1% (+/- 1.6) 69.6% 17.4% 69.9% 4.2 24.9% 164 Texas 17.1% (+/- 1.1) 165 31.3% (+/- 1.3) 29.2% (+/- 1.4) 70.3% 17.2% 59.4% 6.3 18.2% 1,233 Utah 19.2% (+/- 1.0) 7 22.9% (+/- 0.9) 24.3% (+/- 1.0) 70.1% 11.0% 56.0% 1.5 10.6% 37 Vermont 22.7% (+/- 1.3) 2 29.3% (+/- 1.4) 23.7% (+/- 1.4) 70.8% 11.4% 64.2% 1.0 16.5% 4 Virginia 15.9% (+/- 1.3) 6 31.2% (+/- 1.6) 27.4% (+/- 1.4) 65.7% 11.0% 60.1% 3.5 19.0% 235 Washington 17.5% (+/- 1.0) 1 30.1% (+/- 1.2) 26.8% (+/- 1.0) 72.8% 12.1% 60.1% 4.4 17.2% 185 West Virginia 7.9% (+/- 0.9) 0 37.1% (+/- 1.6) 33.8% (+/- 1.6) 68.0% 17.1% 68.9% 0.4 28.2% 8 Wisconsin 16.1% (+/- 1.5) 21 28.9% (+/- 1.8) 29.7% (+/- 1.9) 70.4% 12.2% 50.5% 1.6 20.4% 71 Wyoming 17.4% (+/- 1.4) 41 28.7% (+/- 1.6) 24.6% (+/- 1.8) 68.4 10.2% 53.3% 0.7 21.8% 3 U.S. Total N/A 2,318 N/A N/A 68.8% 15.0% 60.1% 5.0 19.6% 9,945 TFAH • healthyamericans.org 31 APPENDIX C: TATE-BY-STATE CHILD AND ADOLESCENT HEALTH INDICATORS S Child/Adolescent Health Indicators AIDS Immunization Gap, % 2013 Census % Uninsured, Cumulative Asthma – 2011 High Fruit Indicator High Vegetable Indicator High of Children Aged 19 to State Population under 18 Cases Under School Students School Students – 2011 School Students – 2011 35 Months Without All Estimates (2012) Age 13 – 2011 (95% Conf Interval) (95% Conf Interval) (95% Conf Interval) Immunizations – 2012 Yr End Alabama 4,833,722 8.2% 77 20.2% (+/- 2.6) 29.2% (+/- 4.1) 14.2% (+/- 2.1) 28.7% (+/- 6.8) Alaska 735,132 16.5% 7 22.1% (+/- 3.0) 32.0% (+/- 3.7) 15.1% (+/- 2.4) 40.5% (+/- 6.8) Arizona 6,626,624 13.7% 47 21.7% (+/- 2.5) N/A N/A 32.5% (+/- 7.5) Arkansas 2,959,373 8.3% 39 23.4% (+/- 2.4) 25.8% (+/- 3.7) 12.4% (+/- 2.0) 33.6% (+/- 7.6) California 38,332,521 9.6% 705 N/A N/A N/A 33.2% (+/- 7.5) Colorado 5,268,367 5.5% 33 N/A N/A N/A 28.3% (+/- 7.9) Connecticut 3,596,080 3.6% 187 N/A 35.2% (+/- 2.6) 11.1% (+/- 2.1) 22.9% (+/- 5.7) Delaware 925,749 10.0% 27 N/A 30.3% (+/- 2.1) N/A 27.4% (+/- 6.7) D.C. 646,449 2.1% 193 N/A N/A N/A 26.6% (+/- 6.2) Florida 19,552,860 13.1% 1,571 21.7% (+/- 1.2) 34.8% (+/- 1.5) 14.9% (+/- 0.8) 31.4% (+/- 7.5) Georgia 9,992,167 12.8% 254 26.8% (+/- 2.8) 30.8% (+/- 2.8) 13.3% (+/- 1.8) 25.3% (+/- 6.8) Hawaii 1,404,054 3.6% 17 N/A 25.5% (+/- 2.1) 13.9% (+/- 1.8) 19.8% (+/- 5.5) Idaho 1,612,136 9.5% 3 19.7% (+/- 2.2) 28.8% (+/- 2.7) 13.5% (+/- 2.5) 37.0% (+/- 8.2) Illinois 12,882,135 6.9% 287 20.7% (+/- 1.7) 31.5% (+/- 3.0) 11.4% (+/- 1.7) 31.5% (+/- 4.9) Indiana 6,570,902 9.6% 57 23.7% (+/- 2.9) 24.6% (+/- 1.9) 9.0% (+/- 1.2) 38.6% (+/- 7.4) Iowa 3,090,416 5.2% 14 16.0% (+/- 2.8) 30.9% (+/- 3.9) 13.2% (+/- 2.4) 25.2% (+/- 6.3) Kansas 2,893,957 6.1% 16 22.6% (+/- 2.6) 26.1% (+/- 2.6) 12.4% (+/- 1.7) 35.0% (+/- 6.7) Kentucky 4,395,295 9.2% 38 26.7% (+/- 2.8) 23.0% (+/- 2.5) 12.3% (+/- 2.9) 31.8% (+/- 6.6) Louisiana 4,625,470 8.3% 138 23.9% (+/- 6.6) 23.8% (+/- 4.4) 11.7% (+/- 1.9) 31.5% (+/- 7.1) Maine 1,328,302 3.8% 9 26.0% (+/- 1.4) 30.8% (+/- 2.1) N/A 27.4% (+/- 6.6) Maryland 5,928,814 7.5% 345 28.7% (+/- 2.7) 34.7% (+/- 2.6) 15.3% (+/- 1.7) 32.9% (+/- 7.1) Massachusetts 6,692,824 3.8% 235 N/A N/A N/A 26.5% (+/- 6.2) Michigan 9,895,622 3.5% 119 24.6% (+/- 1.9) 31.2% (+/- 3.5) 12.6% (+/- 1.7) 29.5% (+/- 7.3) Minnesota 5,420,380 6.2% 29 N/A N/A N/A 33.8% (+/- 7.6) Mississippi 2,991,207 8.9% 57 20.0% (+/- 1.9) 32.3% (+/- 4.1) 16.6% (+/- 1.6) 22.5% (+/- 7.0) Missouri 6,044,171 10.7% 64 N/A N/A N/A 36.1% (+/- 8.0) Montana 1,015,165 11.5% 3 20.3% (+/- 1.2) 26.9% (+/- 1.6) 11.9% 9+/- 1.2) 33.5% (+/- 7.1) Nebraska 1,868,516 9.5% 13 19.2% (+/- 1.7) 26.9% (+/- 1.6) N/A 27.4% (+/- 6.5) Nevada 2,790,136 18.3% 29 N/A N/A 12.2% (+/- 1.2) 34.7% (+/- 6.6) New Hampshire 1,323,459 5.6% 10 26.1% (+/- 2.4) 33.9% (+/- 2.7) 15.5% (+/- 2.3) 19.9% (+/- 5.7) New Jersey 8,899,339 5.6% 816 N/A 30.6% (+/- 3.3) 13.1% (+/- 2.1) 28.5% (+/- 6.4) New Mexico 2,085,287 15.0% 9 24.9% (+/- 1.8) 31.2% (+/- 1.5) 18.1% (+/- 1.5) 28.4% (+/- 6.6) New York 19,651,127 5.6% 2,457 21.3% (+/- 1.0) 36.8% (+/- 2.1) N/A 36.3% (+/- 4.6) North Carolina 9,848,060 8.4% 133 22.8% (+/- 1.7) 30.1% (+/- 2.8) 13.3% (+/- 2.0) 24.6% (+/- 6.5) North Dakota 723,393 5.5% 2 N/A 28.7% (+/- 2.3) 10.8% (+/- 2.2) 27.8% (+/- 7.2) Ohio 11,570,808 6.7% 151 N/A 26.7% (+/- 3.5) 11.2% (+/- 2.1) 33.2% (+/- 6.9) Oklahoma 3,850,568 9.9% 27 22.1% (+/- 2.2) 28.2% (+/- 3.3) 14.1% (+/- 2.6) 39.0% (+/- 7.6) Oregon 3,930,065 5.6% 19 N/A N/A N/A 33.3% (+/- 6.7) Pennsylvania 12,773,801 7.7% 375 N/A N/A N/A 31.7% (+/- 5.9) Rhode Island 1,051,511 6.7% 28 25.3% (+/- 1.8) 34.1% (+/- 2.7) 14.1% (+/- 1.4) 27.5% (+/- 6.5) South Carolina 4,774,839 9.6% 117 23.5% (+/- 2.8) 25.6% (+/- 3.7) 11.7% (+/- 2.0) 28.2% (+/- 6.7) South Dakota 844,877 7.9% 6 N/A 25.9% (+/- 2.4) 11.3% (+/- 1.7) 36.4% (+/- 6.4) Tennessee 6,495,978 7.3% 62 20.7% (+/- 2.1) 28.7% (+/- 2.9) 13.2% (+/- 1.3) 26.9% (+/- 6.8) Texas 26,448,193 15.6% 396 21.4% (+/- 2.2) 29.9% (+/- 2.0) 10.7% (+/- 1.5) 35.2% (+/- 4.0) Utah 2,900,872 8.5% 20 20.7% (+/- 1.8) 31.7% (+/- 2.8) 15.3% (+/- 2.6) 27.0% (+/- 7.2) Vermont 626,630 4.6% 6 N/A 36.1% (+/- 2.7) 16.9% (+/- 1.0) 36.8% (+/- 6.7) Virginia 8,260,405 5.7% 188 22.0% (+/- 3.6) 30.2% (+/- 3.0) 12.0% (+/- 2.7) 30.2% (+/- 7.7) Washington 6,971,406 4.9% 34 N/A N/A N/A 34.8% (+/- 7.2) West Virginia 1,854,304 8.4% 11 22.7% (+/- 2.7) 33.0% (+/- 4.9) 18.7% (+/- 5.1) 39.2% (+/- 7.9) Wisconsin 5,742,713 4.9% 35 N/A 32.9% (+/- 2.4) 12.7% (+/- 1.9) 24.8% (+/- 6.5) Wyoming 582,658 9.5% 2 25.3% (+/- 1.8) 29.8% (+/- 1.9) 17.5% (+/- 1.6) 32.8% (+/- 6.8) U.S. Total 316,128,839 8.9% 9,521 N/A N/A N/A 31.6% (+/- 1.4) 32 TFAH • healthyamericans.org High School Dropout Infant % Low Tobacco: Current Obese – 2011 High Pre-Term Births % Rate - % of 9th- to Mortality – Per Birthweight Obese: % of 10 to 17 Smokers High School State School Students of live births 2012 12th-graders who 1,000 Live Births Babies – 2012 Year Olds (2011) Students 2011 (95% Conf Interval) Preliminary Data dropped out of public 2010 Final Data Preliminary Data (95% Conf Interval) schools, 2009-10 Alabama 8.7 10.0% 17.0 (+/- 3.9) 18.6% (+/- 3.9) 14.6% 22.9% (+/- 3.6) 1.8% Alaska 3.8 5.6% 11.5 (+/- 2.0) 14.0% (+/- 3.3) 9.2% 14.1% (+/- 3.8) 6.9% Arizona 6.0 6.9% 10.9 (+/- 1.9) 19.8% (+/- 4.6) 11.6% 17.4% (+/- 2.8) 7.8% Arkansas 7.3 8.7% 15.2 (+/- 2.1) 20.0% (+/- 4.2) 13.3% 18.2% (+/- 3.2) 3.6% California 4.7 6.7% N/A 15.1% (+/- 4.1) 9.6% N/A 4.6% Colorado 5.9 8.8% 7.3 (+/- 2.4) 10.9% (+/- 3.6) 10.4% 15.7% (+/- 3.1) 5.3% Connecticut 5.3 7.9% 12.5 (+/- 2.7) 15.0% (+/- 3.2) 9.7% 15.9% (+/- 3.0) 3.0% Delaware 7.7 8.3% 12.2 (+/- 1.5) 16.9% (+/- 4.1) 12.3% 18.3% (+/- 2.2) 3.9% D.C. 7.9 9.6% N/A 21.4% (+/- 5.5) 12.8% N/A 7.0% Florida 6.5 8.6% 11.5 (+/- 2.3) 13.4% (+/- 3.3) 13.7% 14.3% (+/- 1.5) 2.3% Georgia 6.4 9.3% 15.0 (+/- 2.3) 16.5% (+/- 3.8) 12.7% 17.0% (+/- 3.0) 3.8% Hawaii 6.2 8.1% 13.2 (+/- 2.4) 11.5% (+/- 2.6) 12.2% 10.1% (+/- 1.9) 5.2% Idaho 4.8 6.4% 9.2 (+/- 1.6) 10.6% (+/- 3.4) 10.3% 14.3% (+/- 3.6) 1.4% Illinois 6.8 8.1% 11.6 (+/- 1.7) 19.3% (+/- 3.9) 12.0% 17.5% (+/- 2.4) 2.9% Indiana 7.6 7.9% 14.7 (+/- 1.8) 14.3% (+/- 3.7) 10.9% 18.1% (+/- 2.3) 1.6% Iowa 4.9 6.7% 13.2 (+/- 3.2) 13.6% (+/- 3.2) 11.5% 18.1% (+/- 2.8) 3.4% Kansas 6.2 7.1% 10.2 (+/- 1.5) 14.2% (+/- 3.6) 11.0% 14.4% (+/- 2.6) 2.1% Kentucky 6.8 8.6% 16.5 (+/- 2.5) 19.7% (+/- 3.9) 12.7% 24.1% (+/- 3.3) 3.2% Louisiana 7.6 10.8% 16.1 (+/- 2.6) 21.1% (+/- 4.0) 15.3% 21.8% (+/- 4.4) 4.8% Maine 5.4 6.6% 11.5 (+/- 1.4) 12.5% (+/- 3.0) 9.2% 15.2% (+/- 1.3) 4.2% Maryland 6.8 8.8% 12.0 (+/- 1.7) 15.1% (+/- 3.7) 12.2% 12.5% (+/- 3.5) 2.7% Massachusetts 4.4 7.5% 9.9 (+/- 1.8) 14.5% (+/- 3.5) 10.0% 14.0% (+/- 1.9) 2.8% Michigan 7.1 8.4% 12.1 (+/- 1.6) 14.8% (+/- 3.6) 11.8% 14.0% (+/- 2.8) 4.3% Minnesota 4.5 6.6% N/A 14.0% (+/- 3.7) 10.2% N/A 1.6% Mississippi 9.7 11.6% 15.8 (+/- 2.2) 21.7% (+/- 4.4) 17.1% 17.9% (+/- 3.0) 7.4% Missouri 6.6 7.7% N/A 13.5% (+/- 3.0) 11.7% N/A 3.5% Montana 5.9 7.4% 8.5 (+/- 1.1) 14.3% (+/- 3.4) 11.2% 16.5% (+/- 2.2) 4.3% Nebraska 5.3 6.7% 11.6 (+/- 1.2) 13.8% (+/- 3.1) 11.1% 15.0% (+/- 1.8) 2.2% Nevada 5.6 8.0% N/A 18.6% (+/- 4.2) 13.0% N/A 4.5% New Hampshire 4.0 7.3% 12.1 (+/- 1.7) 15.5% (+/- 3.6) 9.3% 19.8% (+/- 3.8) 1.2% New Jersey 4.8 8.2% 11.0 (+/- 2.0) 10.0% (+/- 2.9) 11.2% 16.1% (+/- 3.2) 1.6% New Mexico 5.6 8.8% 12.8 (+/- 2.1) 14.4% (+/- 3.7) 11.5% 19.9% (+/- 2.4) 6.9% New York 5.1 7.9% 11.0 (+/- 1.3) 14.5% (+/- 3.2) 10.7% 12.5% (+/- 1.9) 3.6% North Carolina 7.0 8.8% 12.9 (+/- 3.2) 16.1% (+/- 4.0) 12.0% 17.7% (+/- 3.0) 4.7% North Dakota 6.8 6.2% 11.0 (+/- 1.7) 15.4% (+/- 3.8) 9.9% 19.4% (+/- 3.0) 2.2% Ohio 7.7 8.6% 14.7 (+/- 3.1) 17.4% (+/- 3.7) 12.1% 21.1% (+/- 5.5) 4.2% Oklahoma 7.6 8.0% 16.7 (+/- 3.0) 17.4% (+/- 3.6) 13.0% 22.7% (+/- 3.8) 2.4% Oregon 5.0 6.1% N/A 9.9% (+/- 2.8) 9.1% N/A 3.4% Pennsylvania 7.3 8.1% N/A 13.5% (+/- 3.5) 10.8% N/A 2.1% Rhode Island 7.1 8.0% 10.8 (+/- 2.3) 13.2% (+/- 3.3) 11.0% 11.4% (+/- 2.7) 4.6% South Carolina 7.4 9.6% 13.3 (+/- 3.0) 21.5% (+/- 4.1) 13.7% 19.1% (+/- 3.2) 3.0% South Dakota 6.9 6.2% 9.8 (+/- 2.0) 13.4% (+/- 3.3) 10.7% 23.1% (+/- 6.7) 2.6% Tennessee 7.9 9.2% 15.2 (+/- 1.6) 20.5% (+/- 4.2) 12.5% 21.6% (+/- 3.4) 2.7% Texas 6.1 8.3% 15.6 (+/- 2.0) 19.1% (+/- 4.5) 12.4% 17.4% (+/- 2.0) 2.7% Utah 4.9 6.8% 8.6 (+/- 1.7) 11.6% (+/- 3.3) 10.2% 5.9% (+/- 1.2) 2.6% Vermont 4.2 6.2% 9.9 (+/- 2.0) 11.3% (+/- 2.7) 8.7% 13.3% (+/- 1.3) 2.4% Virginia 6.8 8.1% 11.1 (+/- 2.5) 14.3% (+/- 3.6) 11.3% 15.0% (+/- 4.1) 2.1% Washington 4.5 6.1% N/A 11.0% (+/- 3.1) 9.9% N/A 4.2% West Virginia 7.3 9.2% 14.6 (+/- 2.4) 18.5% (+/- 3.4) 12.4% 19.1% (+/- 3.3) 4.0% Wisconsin 5.8 7.1% 10.4 (+/- 1.6) 13.4% (+/- 3.1) 10.5% 14.6% (+/- 2.2) 2.2% Wyoming 6.8 8.5% 11.1 (+/- 1.4) 10.7% (+/- 4.2) 10.8% 22.0% (+/- 3.0) 6.0% U.S. Total 6.2 8.0% N/A NA 11.5% N/A 3.4% TFAH • healthyamericans.org 33 APPENDIX D: STATE-BY-STATE OTHER PUBLIC HEALTH INDICATORS Other Public Health Indicators Health Professions Health Professions Health Professions ASPR Hospital 2013 Census Population Nursing Shortage State Service Areas Primary Service Areas Mental Service Areas Dental Preparedness Program Estimates Estimates (2010) Care (As of 7/29/13) Health (As of 7/29/13) Care (As of 7/29/13) Funding by State 2013 Alabama 4,833,722 79 50 61 -200 $5,118,503 Alaska 735,132 82 52 50 -2,300 $1,186,273 Arizona 6,626,624 142 95 153 -12,500 $6,676,397 Arkansas 2,959,373 71 42 40 -2,700 $3,317,556 California 38,332,521 503 315 325 -47,600 $27,009,882 Colorado 5,268,367 106 56 78 -10,900 $5,359,548 Connecticut 3,596,080 37 28 37 -11,100 $3,953,533 Delaware 925,749 9 10 6 -1,300 $1,367,644 D.C. 646,449 14 8 10 -3,000 $1,081,425 Florida 19,552,860 253 140 218 -32,700 $18,667,091 Georgia 9,992,167 183 84 141 -16,400 $9,860,862 Hawaii 1,404,054 23 27 19 -4,500 $1,814,414 Idaho 1,612,136 70 31 63 -800 $2,014,703 Illinois 12,882,135 226 119 159 -9,300 $10,293,152 Indiana 6,570,902 101 52 45 -8,200 $6,765,086 Iowa 3,090,416 115 66 116 -3,400 $3,443,593 Kansas 2,893,957 153 60 126 -1,000 $3,256,875 Kentucky 4,395,295 123 92 85 1,200 $4,692,988 Louisiana 4,625,470 118 107 102 100 $4,880,449 Maine 1,328,302 64 49 73 -2,500 $1,783,552 Maryland 5,928,814 48 48 39 -7,000 $6,078,794 Massachusetts 6,692,824 62 57 62 -16,100 $6,826,760 Michigan 9,895,622 225 141 161 -3,100 $10,050,238 Minnesota 5,420,380 107 55 115 -4,400 $5,625,009 Mississippi 2,991,207 107 40 108 -500 $3,367,202 Missouri 6,044,171 191 66 149 -12,900 $6,286,904 Montana 1,015,165 94 62 70 -500 $1,456,039 Nebraska 1,868,516 103 74 71 -2,400 $2,264,734 Nevada 2,790,136 66 28 45 -4,100 $3,109,454 New Hampshire 1,323,459 24 18 21 -3,300 $1,772,062 New Jersey 8,899,339 30 31 35 -19,600 $8,995,320 New Mexico 2,085,287 94 61 76 -3,100 $2,489,717 New York 19,651,127 179 135 123 -21,500 $11,325,062 North Carolina 9,848,060 117 84 128 -8,100 $9,713,825 North Dakota 723,393 79 50 34 -900 $1,149,903 Ohio 11,570,808 124 90 119 -12,100 $11,647,346 Oklahoma 3,850,568 169 107 94 -500 $4,124,808 Oregon 3,930,065 103 66 87 -5,300 $4,201,841 Pennsylvania 12,773,801 149 113 151 -21,100 $12,773,893 Rhode Island 1,051,511 15 12 16 -3,000 $1,517,061 South Carolina 4,774,839 91 44 78 -5,200 $4,969,338 South Dakota 844,877 84 49 54 -200 $1,286,715 Tennessee 6,495,978 99 62 134 -18,500 $6,632,034 Texas 26,448,193 341 314 221 -41,900 $24,797,333 Utah 2,900,872 55 34 48 -1,500 $3,170,652 Vermont 626,630 29 22 23 -600 $1,104,633 Virginia 8,260,405 84 47 82 -11,000 $8,231,128 Washington 6,971,406 145 112 106 -8,800 $6,997,703 West Virginia 1,854,304 93 77 89 700 $2,290,487 Wisconsin 5,742,713 100 101 88 500 $5,995,149 Wyoming 582,658 38 16 21 -1,200 $1,044,613 U.S. Total 316,128,839 5,768 3,739 4,595 -405,800 $303,839,283 34 TFAH • healthyamericans.org Endnotes 1 nstitute of Medicine. The Future of the I Dr. Lawrence Gostin, Georgetown Law 19 Meyer J. and Weiselberg L. “County and Public’s Health in the 21st Century. Washing- Center; Dr. Peggy Hamburg, NTI; Dr. James City Health Departments: The Need for ton, D.C, 2003. U.S. Centers for Disease J. James, American Medical Association; Dr. Sustainable Funding and the Potential Ef- Control and Prevention. Public Health’s James Marks, Robert Wood Johnson Foun- fect of Healthcare Reform on their Opera- Infrastructure — A Status Report. Atlanta, dation; Dr. Dennis O’Leary, Joint Com- tions.” Health Management Associates, Georgia, 2001. Trust for America’s Health. mission on Accreditation of Healthcare A Report for the Robert Wood Johnson Blueprint for a Healthier America: Modernizing Organizations; Dr. Alonzo Plough, The Cali- Foundation and the National Association the Federal Public Health System to Focus on Pre- fornia Endowment; Dr. Kathleen Toomey, of County & City Health Officials. Decem- vention and Preparedness. 2008. Emory University; Dr. Kenneth Warner, ber 2009. University of Michigan. 2 Adjusted for inflation. 20 ays GP and Smith SA. “Geographic Vari- M 9 nstitute of Medicine. For the Public’s Health: I ation in Public Health Spending,” 2009. 3 ASTHO. Budget Cuts Continue to Affect the Investing in a Healthier Future. April 2012. Health of Americans. October 2013. www.astho. 21 Mays GP and Smith SA. Evidence Links org/budget-cuts-Nov-2013. (accessed March 10 RESOLVE. “Transforming Public Health: Increases in Public Health Spending to 2014). Emerging Concepts for Decision Making in Declines in Preventable Deaths. Health Af- a Changing Public Health World.” 2012. fairs, 30(8): 1585-1593, 2011. 4 ational Association of County and City N Health Officials. Local Health Department Job 11 RESOLVE. “Transforming Public Health: 22 Public Health Infrastructure -- A Status Losses and Program Cuts: Findings from the Emerging Concepts for Decision Making in Report (Atlanta, Georgia: Centers for Dis- 2013 Profile Study. Washington, D.C.: NAC- a Changing Public Health World.” 2012. ease Control and Prevention, 2001); CHO, 2013. 12 ESOLVE—Public Health Leadership R 23 The Future of the Public’s Health in the 21st 5 nstitute of Medicine. For the Public’s Health: I Forum. “Defining and Constituting Century (Washington, D.C.: National Acad- Investing in a Healthier Future. April 2012. Foundational “Capabilities” and “Areas” emies Press for the Institute of Medicine, Version 1 (V-1). 2014. http://www.re- 2003). 6 ESOLVE. “Transforming Public Health: R solv.org/site-healthleadershipforum/ Emerging Concepts for Decision Making in 24 Trust for America’s Health. Blueprint for files/2014/03/Articulation-of-Founda- a Changing Public Health World.” 2012. a Healthier America: Modernizing the Federal tional-Capabilities-and-Foundational- Public Health System to Focus on Prevention 7 ealth Resources and Services Administra- H Areas-v1.pdf (accessed April 2014). and Public Health. October 2008. tion. “About HRSA.” U.S. Department of 13 ays GP and Public Health Cost Estimation M Health and Human Services. http://www. 25 New York Academy of Medicine and Trust Workgroup. Estimating the Costs of Founda- hrsa.gov/about/default.htm. (accessed for America’s Health. 2013. A compendium tional Public Health Capabilities: A Recom- January 23, 2008). of proven community-based prevention pro- mended Methodology. Lexington: University of grams. New York, NY: New York Academy 8 rust for America’s Health. Public Health T Kentucky, 2014. http://works.bepress.com/ of Medicine. http://www.tfah.org/re- Leadership Initiative An Action Plan for Healthy glen_mays/128 (accessed April 2014). port/110/ (accessed April 2014). People in Healthy Communities in the 21st Cen- 14 ays GP and Public Health Cost Estimation M tury. Washington, D.C.: Trust for America’s 26 New York Academy of Medicine. 2010. A Workgroup. Estimating the Costs of Founda- Health, March 22, 2006. http://healthy- compendium of proven community-based pre- tional Public Health Capabilities: A Recom- americans.org/policy/files/ActionPlan.pdf vention programs. New York, NY: New York mended Methodology. Lexington: University of The “Action Plan” has been signed onto by Academy of Medicine. Kentucky, 2014. http://works.bepress.com/ a range of public health experts, including glen_mays/128 (accessed April 2014). 27 evi, Jeffrey, Laura M Segal, and Chris- L Rachel Block, United Hospital Fund; Dr. sie Juliano. 2008. Prevention for a healthier Georges Benjamin, American Public Health 15 elcome to the Public Health Accredita- W America: investments in disease prevention yield Association; Dr. Jo Ivey Boufford, New York tion Board. In Public Health Accreditation significant savings, stronger communities. Wash- University Wagner; Shannon Brownlee, Board. http://www.phaboard.org/ (ac- ington, D.C.: Trust for America’s Health, New America Foundation; Maureen By- cessed November 9, 2012). accessed at http://healthyamericans.org/ rnes, Human Rights Fund (formerly with 16 ublic Health Accreditation Board. Stan- P reports/prevention08/Prevention08.pdf The Pew Charitable Trusts); Dr. Lawrence dards and Measures. Alexandria, VA: Pub- Deyton, Veterans Health Administration; 28 The Community Guide to Preventive Services. lic Health Accreditation Board, 2011. Dr. Jonathan Fielding, Los Angeles County Centers for Disease Control and Preven- Department of Health Services; Dr. David 17 Ibid. tion. http://www.thecommunityguide. Fleming, The Bill & Melinda Gates Founda- org/index.html (accessed April 2014). 18 Ibid. tion; Dr. C. Earl Fox, University of Miami; TFAH • healthyamericans.org 35 1730 M Street, NW, Suite 900 Washington, DC 20036 (t) 202-223-9870 (f) 202-223-9871