The Ten Worst States for Your Health, 2013

Arkansas supplants Oklahoma in the 2013 OHPM rankingsas the worst state for your health. 

Arkansas was joined in the bottom ten by five other southern states and four states from the west.  And here's all you need to know about why states in the bottom ten are bad for your health.  Life expectancy in those states is the same as it is in Paraguay - 76.6 years.  This is four years fewer, or an entire Presidential term less, than life expectancy in Massachusetts and Connecticut - the two states at the top of this year's ranking.

Two states – Texas (39, up two places from last year) and West Virginia (38, up five places from last year) – escaped the bottom ten this year.  Kentucky found its way back after one year in 35^th place, and South Carolina entered the bottom ten after dropping eight places from 40^th last year. 

Here are the bottom ten, with the change from last year in parentheses:

41. Kentucky (-6).   Kentucky entered the bottom ten this year not because it did poorly in most rankings (its 44^th place healthy state ranking was its only bottom ten finish), but because it places in the bottom half in every category except Medicaid access.

42. Alabama (+3).  If Alabama’s 35^th place Kids Count health ranking can help to improve its 45^th place healthy state ranking in the future, then it may be poised to escape the bottom ten in the next couple of years.

43. Oklahoma (+7).  Oklahoma moved up from last place this year on the basis of a top 15 performance in Medicaid access and per capita Medicare community spending.  But 43^rd place finishes in both the Healthy State and Kids Count Health rankings cemented its position in the bottom ten.

44. Louisiana (0).  Louisiana is top ten in Medicare community spending and percentage of people on Medicaid, but bottom ten in the Healthy State rankings, the Kids Count health rankings, access to primary care providers, and the percentage of people with employer-based health insurance.

45. New Mexico (+4).  New Mexico is 5^th in percentage of people on Medicaid, and 50^thin percentage of people with employer-based insurance.  Not exactly an indication of a “worker-friendly” environment.

46. Montana (-5). Montana is last in the Kids Count health rankings, and next-to-last in the percentage of people with private health insurance and Medicare community spending.  These offset its middle-of-the-pack healthy state ranking (29^th).

47. Mississippi (0).  At least Mississippi is consistent, finishing 48^th, 47^th, and 47^th during the last three years.  Although it boasts top ten rankings in Medicaid access and Medicare community spending, it is 45th in employer-based insurance, 48^th in the Kids Count health rankings, and 49^thin the Healthy State rankings.  Mississippi has downside potential.  It hasn’t embraced Obamacare Medicaid expansion.  But both Arkansas and Nevada – the bottom two states in the rankings - have.

48. South Carolina (-8). South Carolina’s dive in the rankings is attributable to the fact that it doesn’t do well in any of the categories. In fact, its highest ranking among the states is only 20^th in Medicare community services spending.

49. Nevada (-1). Nevada’s only top thirty ranking is in Medicare community spending.  It is 47^thin the Kids Count health rankings and number of high-quality hospital programs.  But it is one of four bottom ten states to embrace Medicaid expansion.

50. Arkansas (-4).  What is Arkansas’ recipe for failure? Start with a 48^th place Healthy State ranking.  Add in a 49^thplace finish in access to primary care providers, a 46^th place ranking in the percentage of people with employer-based health insurance, and a 44^th place finish in number of high quality hospital programs. Arkansas ranks in the top ten in just one indicator.  It is 9^th in the percentage of people on Medicaid.  Of course, that’s a pre-ACA percentage, but it may explain why Arkansas – a conservative state – has embraced Obamacare’s Medicaid expansion.

Some interesting notes:

Colorado has the greatest difference in the two prevention rankings – it is 11^th in the healthy state rankings, and just 42^ndin the Kids Count health rankings.

Hawaii (+23.8) and Vermont (+22.5) are the only two states that rank more than twenty places better on the average of their prevention rankings than on the average of their health care rankings.  Rhode Island (+17.9) and New Hampshire (+17.9) tie for third on this measure.

Mississippi (-22.9) and Louisiana (-20.6) are the only two states that rank more than twenty places worse on the average of their prevention rankings than on the average of their health care rankings.  Tennessee (-18.6) is third on this measure. 

The states that are most balanced in their prevention and health care rankings are Kansas (+0.6), Colorado (+0.5), and Montana (-0.7).

Connecticut (2^nd overall) favors prevention and public health (+8.2, on average), and Florida (34th overall) favors health care (-11.9, on average).

To see the full rankings, click here.

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/

Better Off With a Federal Exchange

As the December 14^th and February 14^thdates draw near for states to say whether they will create Affordable Care Act health insurance exchanges and what they will look like, the world seems upside down.

Traditional “states’ rights” advocates such as South Carolina, Georgia, Alabama, Louisiana, and Texas all say they will let the federal government set up their exchange.  Historically “strong federal government” allies like Connecticut, Massachusetts, California, New York, and the District of Columbia are setting up their own exchanges.

In all, sixteen states so far have said they want the federal government to set up their exchange, while eighteen states and the District of Columbia have decided to run their own.  The rest are either undecided or looking to partner with the federal government.  No states are considering a multi-state exchange – so much for “selling insurance across state lines.”

The states that are deferring to the federal government cite a number of reasons.   Cost, uncertainty, and too-tight deadlines are the most common.

Politics is also a factor.  Of those sixteen states, only two – Missouri and New Hampshire – have Democratic governors.

But there’s another reason why people living in those states should be pleased that they are deferring to the federal government.  Historically, reluctant states don’t make the health and mental health of their citizens a governmental priority.

In this year’s list of the ten Best States for Your Health, five – Connecticut, Massachusetts, Minnesota, New York, and Vermont – are moving forward with state exchanges.  Three – New Jersey, Pennsylvania, and Utah, are still undecided.  Only two – New Hampshire and Maine – are opting for a federal exchange.

However, in this year’s list of the ten Worst States for Your Health, the results are subtly reversed.  Four – Texas, Alabama, Oklahoma, and Louisiana – are opting for the federal exchange.  Only three – New Mexico, Nevada, and Mississippi – are planning for state-run exchanges.

That may not seem like a big difference.  But when you look at all the states that have decided, those currently opting to run their own exchanges have an average ranking of just over 20^th in protecting the overall health of their citizens.  Meanwhile, states deferring to the federal government have an average ranking of over 29^th in protecting the overall health of their citizens – over nine places worse.

The difference is just as clear when it comes to spending to protect the mental health of their citizens. 

States opting to run their own exchanges also have an average ranking of just over 20^th when it comes to funding mental health services.  States deferring to the federal government have an average ranking of almost 30^th – nearly ten places worse.

Keep in mind that if all 50 states chose one or the other and divided equally, the best possible average ranking would be 13^thand the worst possible 38^th.

You can view all the states in two new tables here.

Where health and mental health are concerned, “states’ rights” often means state-sanctioned neglect.

There are individual exceptions, of course.  Maine and Alaska historically spend well on mental health, but are opting for a federal exchange.  Nevada and New Mexico do poorly on protecting the overall health of their citizens, but are embracing state-run exchanges.

The take-home lesson, however, is clear.  If your state doesn’t want to create its own exchange, then you are probably better off with the federal exchange.

And if your state is still undecided, be careful about what you wish for.  Floridians, for example, would probably be better off with a federal exchange.  The state ranks 33^rd in overall health and 49^th in mental health spending.

On the other hand, undecided Pennsylvania is 8^thin overall health and 4^th in mental health spending.  There’s a much better chance that a Pennsylvania exchange would be better for its citizens than any the federal government could offer.

The reason for worry in the reluctant states has to do with the flexibility all states will be granted in setting up exchanges. 

Last week, the federal government published a new set of proposed rules governing the “essential benefits package” – the key components of all health insurance plans to be offered through the exchanges beginning in 2014.  States running their own exchanges will be given a great deal of latitude in determining just how rich these benefits will be.

And as the clock ticks toward the Valentine’s Day deadline, it’s hard to imagine new love coming from the states that have rejected our health and mental health so many times before. 

If you would like to schedule Paul Gionfriddo to speak to your group or meeting, please email gionfriddopaul@gmail.com.

The Worst States for Your Health, 2012

What do South Carolina, Texas, Louisiana, and Mississippi have in common?

They all find themselves among the worst states for your health.  And they all have governors who have already declared that they don’t want to expand Medicaid to uninsured adults in their states.

South Carolina ranks 40^th, Texas is 41^st, Louisiana is 44^th, and Mississippi is 47^th in the 2012 Our Health Policy Matters rankings of the states.

The worst state for your health this year is Oklahoma, which dropped from 47^th a year ago. 

New Mexico came in just ahead of Oklahoma, and just below Nevada, Mississippi, and Arkansas.  Rounding out the bottom ten were Alabama, Louisiana, West Virginia, Texas, and Montana.

Led by middle-of-the-pack Medicare and Medicaid community spending, West Virginia escaped the bottom of the rankings this year.  Its 43^rd place finish represents an improvement of seven places over last year’s worst-in-the-nation finish. 

On the other hand, Texas had a comparable fall into the bottom ten, plunging five places to a tie for 41^st from its finish last year, on the heels of bottom ten Healthy State and KidsCount Health rankings. 

Kentucky made the biggest jump out of the bottom ten during the past year, from 45^th in 2011 to 35^th in 2012.

The states with governors who have said that they will reject the Medicaid expansion are among those states whose citizens probably need it the most.

In addition to South Carolina, Texas, Louisiana, and Mississippi, three other states have governors who declared that they would refuse to expand the Medicaid program in 2014 – despite the federal government’s offer to pick up 100% of the cost in the first three years and at least 90% ever after.  Florida landed at the cusp of the bottom third, finishing in 33^rd place overall.  Georgia just managed to stay out of the bottom ten.  Only Iowa, which ranked 19^th, escaped from the bottom half of the rankings.

But what is most interesting about the rejecting states is that they all do a relatively poor job of directing their current Medicaid money toward home and community-based services.

• Georgia ranks last in that category, Florida ranks 43^rd, Mississippi ranks 42^nd, Louisiana ranks 35^th, South Carolina ranks 34^th, Texas ranks 32^nd, and Iowa ranks 25^th.

And as a group, their Healthy State rankings – a measure of how effectively the states support public health – aren’t any better.

• Mississippi ranks 50^th (last), Louisiana ranks 49^th, South Carolina ranks 45^th, Texas ranks 44^th, Georgia ranks 37th, Florida ranks 33^rd, and Iowa ranks 17^thon that measure.

The states at or near the bottom of the rankings should also be nervous about the changes Paul Ryan has proposed for the Medicare program.

• Medicare spending on community services is the one area in which many of these states shine.  Community per capita Medicare spending in Oklahoma, for example, is 13^th in the nation.  In Nevada it is 16^th. In Mississippi it is 10^th.  In Alabama it is 8^th.  And in Louisiana it is 3rd.  (Florida is first in this category.)

Ryan’s proposed transition of Medicare to a voucher program, with a cap on the value of the voucher, could turn out to be the first step in a long process that undermines these community-based Medicare services. 

Medicare recipients down the road might want to use their voucher money to continue to pay for these, but they might have to use it to cover hospital stays instead.

The full rankings are available here.

The OHPM rankings are a modest attempt to average rankings from several independent sources to provide an overall picture, relative to the other states, of both the health of a state’s population and the overall quality and accessibility of the state’s health care services. 

The rankings factor in:

• Public health and prevention
• Access to primary care services
• Access to home and community-based health services, especially for low income and elderly people
• Access to quality hospital care, including general and specialty hospital programs (including mental health)
• Private insurance coverage of the population

This year’s rankings incorporated three recently-released independent rankings.  These were the 2012 KidsCount Health Rankings, the 2011 Healthy State Rankings, and the 2012 U.S. News and World Report Hospital Ratings.  They also factored in the most recent CMS data on state per capita community (non-hospital and non-nursing home) Medicare and Medicaid spending on community health care services, and Kaiser State Health Facts data on the state’s prevalence of nurse practitioners and the state percentage of privately-insured individuals.     

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.

The Best States for Your Health, 2012

If you want to live in the state where Medicare pays the most per capita for home-based care for elders, then Florida is the place for you.  On the other hand, if you prefer the state which does the best job of protecting the health of its children, then head to Vermont.

But if you want to live in the best state for your overall health, then Connecticut is where you want to be.

Connecticut is the new number one in the 2012 Our Health Policy Matters Best States for Your Health Rankings.  Last year’s runner-up switched places with last year’s winner, Massachusetts, dropping its northern neighbor into second.

The OHPM rankings are a compilation of seven independent rankings and ratings of states.  The sources from which the final OHPM rankings are drawn are described below. 

Connecticut made the top by scoring well across the board, finishing second in Medicaid spending on community services, third in the Healthy State rankings and in the percentage of people privately insured, fourth in access to nurse practitioners, sixth in the KidsCount children’s health rankings, 12^th in Medicare spending on community services, and 20^thin in-state access to high quality hospital programs.

Northeastern states all did well. 

In addition to Connecticut and Massachusetts in the top two places, New Jersey, which took 3^rd, and New Hampshire, which tied for 4^th, also placed in the top five.  New York came in 6^th, Vermont 7^th, and Maine tied for 8^th with Pennsylvania.  Rhode Island finished just outside the top ten, placing 11^th.

The two states that broke up  the northeast’s logjam at the top were Minnesota, which moved up two places from 6^th place last year into a tie for fourth, and Utah, which went from 5^th last year to a tie for 8^th in 2012.

New York, Maine, and Pennsylvania all made big moves into the top ten.  Buoyed by top-six rankings in community Medicare and Medicaid spending and access to high quality hospital programs, New York jumped from 19^th place last year to 6^th. Maine moved up from 18^th on the strength of strong Healthy State and KidsCount children’s health rankings.  Pennsylvania, led by a 3^rd place finish in the number of high quality hospital programs, moved all the way up to the top ten from 22^nd.

Washington and Hawaii dropped out of the top ten, falling to 16^th and 17^th place.

Five states including Florida and Vermont shared first place honors in the seven categories.

In addition to topping the states in the KidsCount health ranking, Vermont finished first in the Healthy State ranking.  New Hampshire took first in the percentage of the population privately insured and in the number of nurse practitioners per capita.  California, which finished 23^rd overall, led all the states in the number of high quality hospital programs, and Alaska, which finished 30^thoverall, was first in per capita Medicaid community spending.

Florida finished 33^rd overall, down three places from last year.  While it was in the top ten in two categories – Medicare community spending – which it led for the second straight year – and in-state access to high quality hospital programs where it placed 9^th, it was near the bottom in two others – 43^rdin Medicaid spending on community health services and 47^th in percentage of people with private insurance.

The full rankings are available here.

The OHPM rankings are a modest attempt to average rankings from several independent state ranking sources to provide an overall picture, relative to the other states, of both the health of a state’s population and the overall quality and accessibility of the state’s health care services. 

The rankings factor in:

• Public health and prevention
• Access to primary care services
• Access to home and community-based health services, especially for low income and elderly people
• Access to quality hospital care, including general and specialty hospital programs (including mental health)
• Private insurance coverage of the population

This year’s rankings incorporated three recently-released independent rankings.  These were the 2012 KidsCount Health Rankings, the 2011 Healthy State Rankings, and the 2012 U.S. News and World Report Hospital Ratings.  They also factored in the most recent CMS data on state per capita Medicare and Medicaid spending on community (non-hospital and non-nursing home) health care services, and Kaiser State Health Facts data on each state’s prevalence of nurse practitioners and percentage of privately-insured individuals.      

Next Week: The Worst States for Your Health, 2012

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!