The Best States for Your Health, 2013

After a year in second place, Massachusetts is once again the best state for your health in the 2013 Our Health Policy Matters rankings.

In first place in 2011, Massachusetts dropped to second last year behind Connecticut.  It edged out Connecticut this year based on the rankings of all fifty states in a combination of seven national source rankings and/or spending categories.

Here are the top ten states, with the change from last year’s ranking in parentheses.

1. Massachusetts (+1).  Among the seven components of the rankings, Massachusetts was only 4^th in the Healthy State rankings, and 11^th in the Kids Count health rankings.  But it earns its top rank overall because of consistently high placements in five other health care rankings.

2. Connecticut (-1).  Last year’s winner, Connecticut ranks 2^ndoverall in the Kids Count health rankings and in the percentage of residents with employer-based private insurance.  But it is only in the middle of the pack (20^th) in total number of high-quality hospital programs.

3. New York (+3). Never highly ranked in the healthy state rankings (18^th this year), New York has jumped from 19^thto 3^rd in two years on the strength of its hospitals, and good access to care for both younger and older residents.

4. Vermont (+3). Vermont tops the healthy state rankings and is 4^th in the Kids Count health rankings.  With an earlier investment in universal health care for its residents offsetting its lack of high-quality hospital programs, it may go higher in the future.

5. Maine. (+3). Maine tops three individual categories – the Kids Count health rankings, Medicaid access, and primary care access – accounting for its three-place gain this year.

6. Minnesota (-2). Minnesota scores highly in the Healthy State rankings, and also has high-quality hospital programs and a highly-insured population.Wisconsin (+6).  

7. Wisconsin owes its improvement in the ranking to healthy kids (3^rd) and solid performances in most other categories.  But it lags a bit in the Healthy State and primary care access rankings.

8. Utah (0). Utah scores well in the Healthy State rankings (7^th), but less well in the Kids Count health rankings (14^th).  It also has a high percentage of its population covered by employer-based insurance.

9. Washington (+7). Like Wisconsin, Washington made a big move into the top ten this year on the strength of a solid Kids Count health ranking (6^th).

10. Maryland (+2).  Maryland is in the top ten in the Kids Count ranking and in the percentage of its population with employer-based insurance.

In individual categories, Maine had the most first place rankings – the Kids Count health ranking, the primary care access ranking, and a tie for first in Medicaid access. California (19^th overall, up 3 places from last year) placed first in the number of high quality hospital programs and tied for first in the Medicaid access rankings.  Vermont topped the Healthy State rankings and tied for first in Medicaid access.  New Hampshire (11^th overall, after a 4^th place showing last year) placed first in employer-based health insurance. 

And Florida (34^th this year, down one place from last year) was first in community Medicare spending.

These rankings are the last before some significant Obamacare changes go into effect next year. For example, Vermont (ranked 4^th), Maine (5^th), Wisconsin (7^th), and Rhode Island (12^th) have all announced plans to cut their Medicaid rolls to encourage people to enroll in the exchanges, according to an article this week in Kaiser Health News.   Next year’s rankings may be adjusted to take into account insurance exchange enrollments in all the states.

Washington (9^th), Delaware (18^th), and Oklahoma (43^rd) were the biggest gainers this year.  They all gained seven spots in the rankings. New Jersey (13^th) experienced the biggest drop – 10 places. Virginia (23^rd) lost nine places, and Pennsylvania (16^th) and South Carolina (48^th) each lost eight.

Next week: the ten worst states for your health.

To see the full rankings of all fifty states, click here.

How These Rankings Are Developed:

OHPM combines seven rankings of the states to create this Top Ten.

Two of the rankings among the most highly-regarded public health or prevention-focused rankings – the United Health Foundation/APHA/Partnership for Prevention America’s Health Rankings and the Annie E. Casey Kids Count state health rankings.  The most recent America’s Health (Healthy State) Rankings were published in December 2012, and the most recent Kids Count health rankings were released in June 2013.

Because prevention and public health account for 50 percent of the gains in life expectancy over the last century, these two rankings account for 50 percent of the weight in the OHPM rankings.

The other five components of the ranking account for the other 50 percent, and are related to health care access and quality.  This year, they include the number of nurse practitioners and physician assistants per capita in the state (as a measure of the strength of the state’s primary care system), the percentage of state residents with employer-based private insurance and with access to Medicaid (as a measure of the availability of third-party payments for health services in general for the under 65 population), community-based Medicare spending (as a measure of the availability of elder health services), and, from the 2013 US New and World Report Hospital Rankings, the total number of high quality hospital specialty programs in the state (as a measure of the availability of specialty care for all chronic diseases and conditions).

To see the full rankings of all fifty states, click here.

Source links:

http://www.americashealthrankings.org/mediacenter/mediacenter2.aspx

http://www.statehealthfacts.org/comparetable.jsp?ind=125&cat=3

http://datacenter.kidscount.org/data/acrossstates/Rankings.aspx?ind=7248

http://kff.org/medicaid/state-indicator/medicaid-enrollment-as-a-of-pop-fy09/

http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsStateHealthAccountsResidence.html

http://health.usnews.com/best-hospitals/area

http://data.bls.gov/oes/search.jsp?data_tool=OES

http://samhsa.gov/data/NSDUH/2k11State/NSDUHsaeTOC2011.htm

Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/

States Refusing to Set Up Health Exchanges are Helping Their Children - But Not in the Way They Think

The reasons that 25 states chose not to participate in creating a new health exchange aren’t exactly the ones they’ve been claiming – that Obamacare is too complicated, too anti-consumer, or too politically unpopular. 

The truth is that they have never done a very good job of protecting the health and well-being of their people – especially their children – and they were not ready to start now.

Now that all fifty states have decided whether or not they will at least participate in running their own health insurance exchanges as allowed by the Affordable Care Act (you can see the updated information about what each state decided on my state rankings page), a clear picture is emerging of what distinguished the states choosing to participate from those refusing to do so.

On the whole, when compared to one another, the 25 states that have chosen to participate in running their exchanges (17 by themselves, 8 in partnership with the federal government)do a much better job of taking care of their people than do the 25 states that have deferred to the federal government.

So, just as we imagined a few months ago, residents in the states that refused are likely to be much better off with the federal government running their exchanges.

In many cases, the differences between the states choosing to participate and those refusing to participate are significant.

Let me illustrate why by showing you some updated numbers.  But first, let me explain briefly how I get to them. 

If you rank the states from best to worst, and assign the ranking of 1 to the best and the 50 to the worst, then two “averages” result.  The average ranking of all the states will be 25.5.  And if you divide the states into two equal groups of 25, with all the top-ranked states in one group and all the bottom-ranked states in the other, then the average ranking of the top group will be 13, and the average ranking bottom group will be 38. 

So keep in mind that 13 is the best possible average ranking for any group of 25 states to have, and 38 is the worst possible.

Now here are some average health-related rankings of the group of 25 states choosing to participate in establishing their own exchanges:

• Overall health (OHPM 2012 rankings):  21.5
• 2012 Kids Count ranking: 21.2
• Percentage of uninsured: 21.7
• Percentage with employer-based insurance: 22.4
• Ranking in spending on mental health: 24.7

And here are the average rankings of the group of 25 states refusing to participate in establishing their own exchanges:

• Overall health (2012 OHPM rankings): 29.5    
• 2012 Kids Count ranking: 29.8
• Percentage of uninsured: 29.3
• Percentage with employer-based insurance: 28.6
• Ranking in spending on mental health: 26.3

In every instance, states choosing to participate in setting up their own exchanges have a much better track record than states refusing to participate.   In only the mental health spending ranking is it even close. 

Those of us living in one of the 25 states refusing to participate ought to be thankful that our state policymakers punted on the exchange, because it is more likely than not that we’ll be much healthier and better insured in the long run. 

Especially our children.  States choosing to participate rank an average of almost ten places better than the states refusing to participate.  Children may have literally won the health lottery when those states decided that the federal government could do a much better job of assuring access to health care in the future.

The differences among the states are not just political ones, either. 

Solid Republican states like Utah, Idaho, and Kentucky are all creating their own exchanges, and states like Arkansas, West Virginia, and South Dakota are partnering with the feds.  Meanwhile, Maine, Wisconsin, Ohio, and Pennsylvania are all letting the federal government create their exchanges.

And the decisions have turned the traditional north/south, “state’s rights” argument on its head.  States’ rights states, like Texas and Florida, are refusing to participate, while states like Connecticut, Massachusetts, and New York are choosing to do so.

States refusing to participate may have tried explaining their decision by claiming that the federal government created a program that was too complex, too controversial, or too anti-consumer.  But those clearly aren’t the reasons. 

No, the real reason is that they know that the federal government has already proven itself over time to be better equipped to protect our health than they are.

To reach Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/

Term Limits Are Bad for Your Health

It costs an average of $6,000 per person per year in federal, state, and local taxes to cover the government’s share of our national health care bill.

The three levels of government pay about 71%, or roughly $1.8 trillion, of our nation’s annual health expenditures.  It is no wonder that most rational people want policymakers to do more to bring these costs under control.

Policy leaders talk all the time about controlling health care expenditures.   This would help.

But if we actually want to reduce costs significantly, we have to invest in prevention and public health.  This is a position I’ve pushed in the past.  All it takes to understand why is to recognize that prevention and public health have been responsible for half of our increased life expectancy during the past century while absorbing less than 5% of our overall health spending.

This is old health policy news.  So why aren’t policymakers doing more in prevention?

The answer may boil down to two words – term limits.  Term limits, it seems, are bad for your health.

State legislators have a direct say in how roughly 40-45% of government health dollars are spent, and an indirect say in much more.  We now have almost twenty years of experience with term limit laws.  States that limit the terms of their state legislators do a worse job protecting the health of their people than states that do not.

Term limit legislation swept through half the nation in the 1990s as citizens sought to rein in the power of lifetime citizen politicians.  California, Colorado, and Oklahoma were the first states to enact them in 1990.  Nebraska, the 21^st, was the most recent in 2000.

There are currently fifteen states with term limits for state legislators.  California and Florida are the most prominent among them.  With just a handful of exceptions, none of them ranks near the top in my States for Your Health ranking, the Healthy State rankings (which focus on public health), or the Kids Count rankings (which focus on children and prevention). 

Only four of these fifteen term-limiting states – Colorado, Nebraska, California, and Maine – make even the top half of the States for Your Health.  Only Colorado, Maine, and Nebraska are in the top 20 in the Healthy Staterankings.  And only California, Maine, and Nebraska are in the top 20 in the Kids Countrankings.

Overall, the average ranking for the fifteen states with term limits is 31^st in all three rankings.  The average ranking for the 35 states without term limits is 23^rd.

Six states – Idaho, Massachusetts, Oregon, Utah, Washington, and Wyoming – enacted term limits and then repealed them.  Their average rank is 13^th in my rankings, 11^th in the Healthy State rankings, and 15^th in the Kids Count rankings.

The reason term limits have such a significant effect on the health of a state’s population may be because term-limited politicians don’t have the time to come up to speed on complex health issues.

Election to office or appointment to a legislative committee does not make one an instant expert on policy.  And term-limited politicians are often political lame ducks the day they get elected, with no incentive to work on issues with a long-term policy payoff.

Public health and prevention initiatives demand patience, with payoffs often measured in decades, not four two-year terms.  For example, reducing smoking prevalence from 42% of the U.S. population in 1965 to 21% in 2006 required a generation of a Surgeon General-led public education campaign, bans on smoking in public places, increased cigarette taxes, and restrictions on sales of tobacco products to minors.  Saving billions in cancer and heart disease costs required this level of ongoing effort.

It also required having in place long-term legislators with whom tobacco lobbyists had to deal.

When the top-ranked state for health, Massachusetts, passed its health reform legislation in 2006 that led to near-universal coverage in the state, two legislators who spearheaded the effort – the Speaker of the House and the President of the Senate – had been in office for 27 years and 13 years, respectively.  And in Connecticut, my second-rated state for health, the current Speaker of the House has been in office for 19 years, and the Senate President has served for 18 years.  Both have considerable achievements in health and environmental health during the past decade – long after term-limiting states would have put them out of office.

In fifteen states, term limits have led us to trust a large portion of $6,000 a year in health spending annually to people without this experience. 

And that has proven to be very bad for our health.

If you have questions about this column or would like to receive an email notifying you when new Our Health Policy Matters columns are published, email gionfriddopaul@gmail.com.

The Worst States for Your Health

Some states do a much worse job than others of keeping their residents healthy and providing for high-quality, affordable health care when their residents need it.  People usually live shorter, less healthy lives in these states than they might if they lived elsewhere.

In my last column, I described a new States for Your Health ranking, and examined the states that finished near the top.

This week, I want to look first at why Florida, ranked first in one of the seven indicators – per capita Medicare spending on non-institution-based services – only finished 30^thoverall.

Florida’s doesn’t invest enough in public health and prevention.  It is 36^th among the states in the 2011 Kids Count rankings, and 37^th in the 2011 Healthy State rankings.  Children in poor environments for their health are more likely to develop both physical and mental illnesses as they age.  Obesity, cancers, heart diseases, and mental illnesses are all expensive, and can cut decades from life expectancy.  

Florida’s care quality rankings are much higher than its prevention rankings.  It is 11^thin the number of times its hospital programs made the U.S. News and World Report national rankings.  These high quality programs are usually found in just a few hospitals in major cities, but this is the case in most states.  It is 16^th in nurse practitioners per 100,000 residents, and 19^th best in keeping Medicaid nursing home and hospital spending under control. 

Florida is, however, is near the bottom (45^thplace) in the percentage of residents with private insurance.  That hurts.

The ten lowest ranked states either score exceptionally low in the prevention or health care rankings, or consistently low across the board: 

50. West Virginia.  The lowest-ranked state isn’t at the bottom in any individual ranking.  It is just near the bottom everywhere – 40^th in the percentage of people with private insurance, 43^rd in the Healthy State rankings, and 44^th in Kids Count.  It broke into the top half in only one ranking, the amount its Medicaid program spends on hospitals and nursing homes.  Even that may not be such a good thing.  While low Medicaid spending on institutions was considered positive in this ranking, it is also an indicator of low spending on health care in general.

49.  Louisiana. Louisiana finished next-to-last in both the Healthy State and Kids Count rankings.  That’s why it’s 49^th here, too.  On the other hand, it was 2^ndin per capita community Medicare spending, and has some quality hospital programs.  It clearly has assets on which to build.

48.  Mississippi.  Mississippi is last in the Kids Count and Healthy State rankings, and next to last in percentage of people with private insurance.  However, it is in the top ten in community-based Medicare spending and in the number of nurse practitioners per 100,000.  Both could contribute to a healthier state in the future.

47.  Oklahoma. Oklahoma is in the bottom ten in nurse practitioners, Kids Count, and Healthy State rankings.  It is also one of 18 states with no highly ranked hospital programs.

45t. Arkansas.  Arkansas’s profile looks similar to some of the others at the bottom.  It has low prevention ratings that bring down its overall ranking, but it is near the top in number of nurse practitioners and limiting Medicaid hospital and nursing home spending. 

45t. Kentucky.  Kentucky isn’t near to the bottom in any single indicator.  It is just consistently weak across the board.

44. New Mexico.  New Mexico is in last place in the percentage of people privately insured.

43. Nevada.  Nevada is in last place in the number of nurse practitioners.

42. Alabama.  Alabama ranks low in prevention and primary care rankings.

41. Montana.  Montana is as high as 25^th in the Healthy State rankings, but it lags in Kids Count and all of the health care rankings.

Two states finished last in individual rankings but did not make the bottom ten.  South Dakota was at the bottom in community-based Medicare spending per capita, but ranked 29^thoverall.  New Jersey spent the most from its Medicaid program on hospital and nursing home care, but still finished 9^th overall.

To see the complete rankings, click here.

If there is a bottom line, it is this.  Despite our discouragement with our public health and health care systems in general, people in nearly every state have at least something for which to be thankful.  And there will be better days ahead for all of us if policy leaders understand that we want them to do more for our health, not less.

Happy Thanksgiving!

The Best States for Your Health

When the Supreme Court reviews the constitutionality of the Affordable Care Act next year, it will do so against the backdrop of both a national sentiment for government to do more in the area of health and significant inequalities in access to health and health care based solely on the states in which people live.  

A new poll released last week by the Robert Wood Johnson Foundation and the Harvard School of Public Health found that 52% of Americans want government to put more resources into health. 

Only 41% gave high grades to our health care system, and only 33% gave our public health system high grades.

We would all like a more effective health and health care system.  But a better national delivery system would make a much bigger difference in some states than in others.

This week, Our Health Policy Matters unveils a new ranking of the states that reflects which states invest most effectively in our health and health care. 

It was created by combining four existing rankings and three new ones.  It includes mental health as well as health, the work of other health professionals in addition to doctors, and availability of community care as well as quality institutional care.  It ultimately rates the states based on how good they are at simultaneously:     

• keeping their children and adults healthy; and 
• taking care of their residents when they are sick or have chronic conditions; and 
• providing for both health and health care at a price their residents can afford. 

Taking everything into account, here are the ten best States for Your Health, and why:

1. Massachusetts.  Massachusetts is the only state with five top five finishes among the seven rankings.  It takes good care of its children, invests in wellness and prevention, has many top-rated hospital programs including one of the highest rated mental health facilities in the country, and insures its population well.  Where health and health care are concerned, every state should want to be more like Massachusetts.
2. Connecticut.  Connecticut is near the top in six of the seven rankings.  Its children, working adults, and elders all thrive on a rich set of high-quality prevention and health care services. The only ranking in which it did not excel was one that measured affordability – the high amount its Medicaid program historically spends on hospital and nursing home care. 
3. New Hampshire.  New Hampshire rates as the best state in the nation in three of the individual rankings I combined – the 2011 Kids Count child health and well-being rankings, and two Kaiser Family Foundation State Health Facts rankings – the number of nurse practitioners per 100,000, and the percentage of people who are privately insured.
4. Vermont.   Vermont is number one in the Healthy State rankings and in keeping its Medicaid hospital and nursing home costs under control.  It has figured out that the best way to control Medicaid spending is to keep its population healthy.
5. Utah.  Utah proves that good health is a conservative value.  It takes good care of its children, promotes healthy lifestyles among its residents, and is home to a high percentage of residents with private employer-based insurance – a key measure of affordability.
6. Minnesota.  Strong in the prevention and public health rankings, Minnesota is also home to a top hospital.  It gives its residents access to quality public health and quality health care at the same time.
7. Washington.  Washington cracked the top ten in only one individual ranking, so it may be a surprise that it is ranked so high when they are all combined.  But it does just about everything well compared to other states, and isn’t close to the bottom in any category. 
8. Hawaii.  Hawaii scores high in prevention and keeps Medicaid institutional spending under control.  It doesn’t have any of the top rated hospital programs.  If it did, it would rank even higher.
9. New Jersey.  New Jersey does especially well by its children and its elders, and is in the top ten in three individual categories.  But it is an expensive state for Medicaid recipients to get sick in, and a lot of that money goes to hospitals and nursing homes. 
10. Wisconsin.Like Washington, Wisconsin is consistently in the top half of the individual rankings.  If its residents were able to spend relatively more of their Medicare dollars on community services and less on institutional ones, it would move up.

There are two states that topped individual rankings that didn’t make the top ten.  California, according to US News and World Report the best state in the nation to find high quality hospital programs, tied for 15^th.  Florida, first in per capital Medicare spending on community services, finished 30^th. 

To see the full ranking of all the states, click here.

Next week:  More about why Florida finished where it did, and a closer look at the ten states that finished near the bottom.

If you have questions about this column, or wish to receive an email notifying you when new Our Health Policy Matters columns are published, email gionfriddopaul@gmail.com.

Note: Here are the rankings I used, the reasons I used each of them, and a link to the 

original data: 

• the 2011 Healthy State Rankings and the 2011 Annie E. Casey Foundation Kids Count state rankings – to measure the effectiveness of public health and overall prevention (including mental illness prevention) activities; 
• the Kaiser Family Foundation (KFF) State Health Facts ranking of the percentage of people with private employer-based insurance – to measure health care access and affordability for workers and families; 
• the KFF State Health Facts ranking of the number of nurse practitioners per 100,000 residents – to measure support for non-physician providers and high quality primary care;
• To measure quality of care and medical professional development, I calculated and ranked the states by the number of times a hospital in a state was included in the 2011 U.S. News and World Report rankings of best hospitals in the country across specialties, including mental health and overall rankings of children’s hospitals (33 states had at least one hospital mention);
• To measure the availability of community-based services for elders, I used the most recently available data from the Centers for Medicare and Medicaid Services reporting per capita state spending in each state on Medicare minus hospital and nursing homespending;
• To measure the effectiveness of state intervention to keep people with disabilities in their homes and out of institutions and as a measure of affordability, I used CMS data to calculate per capita state spending on Medicaid hospital and nursing home care as a negative measure.

Because prevention and health care each account for approximately 50% of the gains in life expectancy over the last century, I gave the two prevention-oriented rankings – the Healthy State and Kids Count rankings  – a combined weight equal to that of the other five.