1. OPPORTUNITIES TO MAKE WISCONSIN THE HEALTHIEST STATE January 2013

2. Introduction Improving broad health outcomes in Wisconsin- how long and how well people live- requires improvement in specific health indicators spanning several health factor areas. The model to the right, from the County Health Rankings, shows four modifiable health factor areas which influence health outcomes.
The health factors are categorized into health behaviors, clinical care, social and economic factors and the physical environment. Each area, and the specific indicators within that area, contributes to the health and well-being of individuals and the community overall. In general, improvements by Wisconsin in each of the health factor areas will produce better health outcomes for all Wisconsin residents.

3. Overview of the Report
Each indicator is presented in a consistent format, comparing the values for:
Wisconsin
the United States
the best and worst states, and
our healthier neighboring state-Minnesota
In this report, the most current data available is presented for selected indicators in the four health factor areas: health behaviors, clinical care, social and economic factors, and the physical environment. Data is reported on between four and seventeen indicators within each health factor area. Each indicator is presented in a consistent format, comparing the results for Wisconsin, the United States, the best and worst states, and Minnesota.

4. For illustration, here is a graphic depicting an example of a possible indicator:
More annual public health spending per capita is linked to increased availability of resources for prevention and health improvement. Therefore, the state with the highest amount of spending per capita is classified as the “best.” Hawaii spends the most at $244 per capita while Wisconsin spends the least at $40 per capita, making it the “worst” state for this indicator. Spending $45 per capita, Minnesota performs just slightly better than Wisconsin. However, Wisconsin and Minnesota are both below the US average of $95 per capita.
Data source: 2011 Trust for America’s Health

5. Tobacco Use
Utah is ranked the best state with only 12 percent of their adult population identifying as current smokers. The U.S. average is 21.2 percent. Kentucky is ranked the worst state with 29 percent adults reporting being current smokers.
Smoking is a frequent cause of preventable death. Its negative impact is not only well established for those who smoke but also for those who breathe secondhand smoke.
Data sources: 2011 Behavioral Risk Factor Surveillance System
Source

6. Tobacco Use
Utah is ranked the best state for having 95% of two-parent and one-parent households report a smoking ban, while the U.S. average was 82 percent. West Virginia is ranked the worst state and has the lowest number of households with a smoking ban in 63% of homes.
Data sources: 2007 Trends in home smoking bans in the USA,
Source

7. Diet and Exercise
Hawaii is ranked the best state with the lowest percent of overweight or obese adults, at 56 percent of Hawaii’s adult population, while the U.S. average is approximately 64 percent of adults. West Virginia and Mississippi are both ranked as the worst states and have the highest percent of overweight and obese adults with 69%.
A nutrient poor diet, excess consumption of calories, and low levels of physical activity are major causes of obesity, premature death and a range of chronic conditions.
Data source: 2011 Behavioral Risk Factor Surveillance System
Source

8. Diet and Exercise
Minnesota and Utah both ranked as the best states (lowest levels of obesity) for overweight or obese children with 23 percent, while the U.S. average is slightly higher at 32 percent. Mississippi ranks as the worst state with 44% of children being overweight or obese.
Healthy behaviors while young are important for later health outcomes.
Data source: 2007 National Survey of Children’s Health
Source

9. Diet and Exercise
Washington is ranked the best state for having 91 percent of children breastfed, while the U.S. average is 75 percent. Louisiana is ranked as the worst state with only 44 percent of children being breastfed.
Breastfeeding provides essential nutrients for infants, has been shown to reduce childhood obesity, and improves the health of mothers.
Data source: 2010 National Immunization Survey, CDC
Source

10. Diet and Exercise
Colorado is ranked as the best state with 84 percent of adults participating in any physical activity within the past month, while the U.S. average is 74 percent. Mississippi is ranked as the worst state with 64% of adults participating in any type of physical activity within the past month.
Data source: 2011 Behavioral Risk Factor Surveillance System
Source

11. Diet and Exercise
Colorado is ranked the best state with 62 percent of adults meeting physical activity requirements, while the U.S. average is 52 percent. Tennessee has the least amount of active adults with only 39% of adults meeting physical activity guidelines and is ranked the worst state.
Data source: 2011 Behavioral Risk Factor Surveillance System
Source

12. Diet and Exercise
Vermont is ranked the best state with 29% of adults eating the recommended 5 servings of fruits and vegetables per day, while the U.S. average is 23 percent. Oklahoma is ranked as the worst state, with only 15 percent of adults meeting the requirement.
Data source: 2009 Behavioral Risk Factor Surveillance System
Source

13. Alcohol & Substance Use
Tennessee is ranked as the best state with having 7 percent of adults that excessively drink, while the U.S. average is 17 percent. Wisconsin is ranked as the worst state with 23 percent of adults being excessive drinkers.
Data source: 2010 Behavioral Risk Factor Surveillance System
Source

14. Alcohol & Substance Use
Iowa is ranked the best state with 5 percent of people aged 12 and over who use illicit drugs, while the U.S. average is slightly above 8 percent. Arkansas is ranked the worst state and has 14 percent of individuals ages 12 and over who use illicit drugs.
Heavy consumption of alcohol and illegal substances can lead to violence, injury, liver disease, cancer, and premature death.
Data source: 2009 SAMSHA, National Survey on drug use and health
Source

15. Sexual Activity
New Hampshire is ranked as the best state for having 16 births per 1, year olds, while the U.S. average is 39 teen births per 1,000. Mississippi is ranked as the worst state and has the highest teen birth rate at 64 per 1, year olds.
High risk sexual practices, e.g., without the use of condoms, leads to increased risk for transmission of a number of sexually transmitted diseases (STDs). STDs can affect the health of men, women, and unborn children. Risky sexual behavior also leads to unwanted pregnancies (which can have long term negative consequences for teenage mothers and their children).
Data source: 2010 STD Surveillance, CDC
Source

16. Sexual Activity
New Hampshire is ranked as the best state for having 160 chlamydia cases per 100,000 population, while the U.S. average is 409 chlamydia cases. Mississippi is ranked as the worst state and has the highest chlamydia rates at 803 per 100,000 population.
STDs can affect the health of men, women, and unborn children. Risky sexual behavior also leads to unwanted pregnancies (which can have long term negative consequences for teenage mothers and their children).
Data source: 2010 STD Surveillance, CDC
Source

17. Sexual Activity
Montana is ranked as the best state with 0.3 syphilis case per 100,000 population while the U.S. average is 4.5 cases per 100,000 population. Louisiana is ranked as the worst state with 12.2 cases of syphilis per 100,000 population.
Data source: 2010 STD Surveillance, CDC
Source

18. Sexual Activity
Wyoming is ranked as the best state with the fewest cases of gonorrhea (7 per 100,000), while the U.S. average is 101 gonorrhea cases per 100,000 population. Missouri is ranked as the worst state and has 210 cases of gonorrhea per 100,000 population.
Data source: 2010 STD Surveillance, CDC
Source

19. Personal Safety
Massachusetts is ranked as the best state with 0.6 traffic fatalities per 100,000 miles driven, while the U.S. average is 1.1 traffic fatalities per 100,000 miles driven. Montana is ranked as the worst state and has the highest number of traffic fatalies, 1.7 per 100,000 miles driven.
Other health behaviors are known to impact health outcomes but do not fit neatly into the previous categories. Accidents are a leading cause of injury and death.
Data source: 2010 Fatal Analysis Reporting System
Source

20. Personal Safety
Hawaii and Washington tie as the best states for having 98 percent of their populations using seatbelts, while the U.S. average is 85 percent. New Hampshire is ranked as the worst state with 72 percent of people using seatbelts.
Seatbelt use is known to reduce fatality rates in motor vehicle accidents.
Data source: 2010 NHTSA’s National Center for Statistics and Analysis
Source

21. Personal Safety
Both Alabama and New Jersey tie for the best states in regards to having 3.9 deaths from falls per 100,000 population, while the U.S. average is 7.5 deaths per 100,000 from falls. Vermont is ranked as the worst state and has 16.9 deaths from falls per 100,000 population.
Deaths from falls measures injury rates in older adults, a leading cause of death.
Data source: 2009 CDC Wonder
Source

22. Access to Care
Massachusetts is ranked as the best state and has 7 percent of their population between the ages of living without health insurance. The U.S. average for uninsured adults between the ages of is 22 percent. Texas is ranked as the worst state and has the highest rates of uninsured individuals between years old with 33 percent of those adults being uninsured.
A prerequisite for access to health care means having adequate coverage for preventive, acute, and chronic care. In addition to having affordable health insurance, access to health care means that the full range of health care services, including medical, dental, mental health, and long term care, are available. Being available means that care is offered when and where it is needed.
Data source: 2010 American Community Survey
Source

23. Access to Care
Hawaii and Massachusetts are ranked as the best states and have only 3 percent of children living without health insurance, while the U.S. average is 10 percent. Nevada is ranked as the worst state and has 19 percent of children living without health insurance.
Data source: 2011 American Community Survey
Source

24. Access to Care
North Dakota is ranked as the best state with 7% of their population not receiving necessary care last year. The U.S. average is 15 percent. Mississippi was ranked as the worst state and has 21 percent of their population who did not receive necessary care in the last year.
Data source: 2010 Behavioral Risk Surveillance System
Source

25. Access to Care
Vermont has the highest number of primary care physicians per population. The U.S. average shows that for every 1093 citizens, there is one primary care provider available. Oklahoma has the least amount of primary care physicians available per population.
*Note: Some of these measures have question marks after the best and worst values since there is conflicting evidence suggesting that the highest and lowest values for these indicators may not necessarily represent the “best” and “worst” values for states.
Data sources: 2009 Health Resources and Services Administration’s Area Resource File
Source

26. Access to Care
South Dakota is ranked as the best state and has 1349 nurses per 100,000 population, while the U.S. average is just 874 nurses per 100,000 population. Nevada is ranked as the worst state and has 605 nurses available per 100,000 population.
*Note: Some of these measures have question marks after the best and worst values since there is conflicting evidence suggesting that the highest and lowest values for these indicators may not necessarily represent the “best” and “worst” values for states.
Data source: 2011 Bureau of Labor Statistics
Source

27. Access to Care
Massachusetts is ranked as the best state and 82 percent of their population who have had a dentist visit within the last year, while the U.S. average is 70 percent of the population. Oklahoma is ranked as the worst state and had 57 percent of their population who have had a dentist visit in the last year.
Data source: 2011 Behavioral Risk Surveillance System
Source

28. Access to Care
Hawaii is ranked as the best state and had 26 preventable hospitalizations per 1,000 Medicare enrollees, while the U.S. average was 68 preventable hospitalizations. Kentucky is ranked as the worst state with 104 preventable hospitalizations per 1,000 Medicare enrollees.
Data source: 2009 Dartmouth Atlas of Health Care
Source

29. Access to Care
Utah is ranked as the best state as they spend $5,031 on personal health spending per capita, while the U.S. average is slightly under $6,815. Massachusetts is ranked as the worst state with over $9,278 on personal health spending per capita.
*Note: Some of these measures have question marks after the best and worst values since there is conflicting evidence suggesting that the highest and lowest values for these indicators may not necessarily represent the “best” and “worst” values for states.
Data source: 2009 Centers for Medicare & Medicaid Services
Source

30. Access to Care
Connecticut is ranked as the best state and has 96 percent of children between months old who have received their recommended vaccines, while the U.S. average is 90 percent. Montana is ranked as the worst state and has the lowest number of immunized children with 83% of month old children having received their recommended vaccines.
Data source: 2010 U.S. National Immunization Survey
Source

31. Quality of Care
Minnesota is ranked as the best state in overall health care quality score of 67.3 (Wisconsin 67.2), while the U.S. average is Texas is ranked as the worst state with an overall quality of care score of
Having access to health care will only improve health if the care provided is safe, effective, patient-centered, and timely.
Median value for states used in place of US average.
Data source: 2011 Agency for Healthcare Research and Quality
Source

32. Quality of Care
Connecticut is ranked as the best state for having 87 percent of pregnant women receiving prenatal care in their first trimester, while the U.S. average is around 77 percent. Texas is ranked as the worst state and has less than 60 percent of pregnant women receiving care in their first trimester.
* Median value for states used in place of US average.
Data source: 2011 National Center for Health Statistics
Source

33. Quality of Care
Massachusetts is ranked as the best state with 76 percent of women receiving mammography's over the age of 50, while the U.S. average is 66 percent. Arkansas is ranked as the worst state with only 58 percent of women receiving mammography's.
Data source: 2009 Dartmouth Atlas of Health Care
Source

34. Education
New Jersey is ranked as the best state and has 65 percent of 3-4 year olds enrolled in preschool. The U.S. average is 48 percent of 3-4 year olds in preschool. Wisconsin falls just short of that number. Nevada is ranked as the worst state with only 30 percent of 3-4 year olds being enrolled in preschool.
There is a well-known relationship between increased education and positive health outcomes. This occurs through several mechanisms such as higher income, better knowledge regarding health behaviors, higher health literacy, and increased access to health care.
Data source: 2010 “Education Counts.” Editorial Projects in Education. Edcounts.org
Source

35. Education
Hawaii was ranked the best state for having around 93% of year olds having obtained a high school degree. The United States average is 83%. New Mexico was ranked the worst state for having 78% of year olds who have obtained a high school degree.
Data source: 2010 American Community Survey
Source

36. Education
Wyoming was ranked the best state for having over 92% of adults over the age of 25 having completed high school. The U.S. average is 86%. Both Texas and California have been ranked as the worst state with only 81% of adults over the age of 25 having obtained a high school degree.
Data source: 2010 American Community Survey
Source

37. Education
Massachusetts was ranked as the best state for having 39 percent of adults over the age of 25 having completed college, while the U.S. average is 28 percent. West Virginia was ranked as the worst state with 18% of adults over the age of 25 having completed college.
Data source: 2010 American Community Survey
Source

38. Education
New Hampshire was ranked as the best state for having the lowest percent of illiterate individuals with 6% of their state population considered illiterate, while the U.S. average was slightly higher at 9%. California was ranked the worst state with 23% of the population considered illiterate.
Data source: 2003 National Center for Education Statistics
Source

39. Employment
North Dakota was ranked as the best state for having 3.5 percent of their workers unemployed, while the U.S. average is 9 percent. Nevada was ranked as the worst state for having 13.5 percent of their workers unemployed.
Employment impacts health through income, health benefits, pension plans, and other pathways to financial security. Higher levels of health are associated with more job control; more security, less stress, and safer work environment (lower exposures to danger or toxins).
Data source: 2011 Bureau of Labor Statistics
Source

40. Income
Maryland was ranked as the best state for having the highest median household income of $68,854 while the U.S. average is around $50,046. Mississippi was ranked as the worst state for having the lowest median household income of $36,851.
Income and health have a well-established reciprocal relationship that operates in both directions: higher income leads to better health and better health leads to higher income. Children who grow up in poverty are more likely to suffer from injuries, physical inactivity and chronic diseases such as asthma.
Data source: 2010 American Community Survey
Source

41. Income
New Hampshire was ranked the best state with having 11 percent of children living in poverty, while the U.S. average is 22 percent of children. Mississippi was ranked the worst state with having 32 percent of children in their state living in poverty.
Data source: 2010 Small Area Income and Poverty Estimates
Source

42. Income
Both Wyoming and Nebraska tied as the best state for having 2 percent of children in low-income households where no adult worked in the past year, while the U.S. average is 5 percent. Mississippi was ranked the worst state with 8.4 percent of children in a low-income household where no adult has worked in the past year.
Data source: 2010 American Community Survey
Source

43. Family & Social Support
New Jersey was ranked as the best state for having 6 suicides per 100,000 population, while the U.S. average is 12 suicides per 100,000 population. Montana was ranked as the worst state with 21 suicides per 100,000 population.
Research has shown that people with greater social support, less isolation, and greater interpersonal trust live longer and healthier lives. Those with greater social support experience lower levels of anxiety and depression and show reduced tendencies towards stress-related behaviors such as overeating and smoking.
Data source: 2009 CDC Wonder
Source

44. Family & Social Support
Utah was ranked as the best state for having 44.5 percent of their population volunteer, while the U.S. average was slightly lower at 26.5 percent. New York was ranked the worst state for having only 20 percent of their population volunteer.
Data source: 2010 Corporation for National and Community Service
Source

45. Family & Social Support
Utah was ranked the best state for having only 6 percent of their population living alone, while the U.S. average was slightly higher at 10 percent. North Dakota was ranked as the worst state for having 13 percent of their population living alone.
Data source: 2010 US Census
Source

46. Community Safety
Maine was ranked the best state for having 122 violent crimes per 100,000 population, while the U.S. average is 404 violent crimes per 100,000 population. Nevada was ranked the worst state for having 661 violent crimes per 100,000 population.
Violence and abuse not only have a physical impact on health with the injuries and fatalities that they cause but they also have a significant psychological impact on the victims and other residents of high crime areas.
Data source: US Department of Justice
Source

47. Community Safety
New Hampshire was ranked the best state for having 1.3 homicides per 100,000 population, while the U.S. average is slightly higher at 5.9 homicides per 100,000 population. Louisiana was ranked the worst state for having 12.9 homicides per 100,000 population.
Data source: 2009 CDC Wonder
Source

48. Environmental Quality
Ten states were ranked the best in regards to having zero days per year with air quality above PM2.5 limit; these states include Minnesota, Florida, Kansas, Missouri, Nebraska, New Mexico, North Dakota, Oklahoma, South Carolina and South Dakota. Wisconsin fares below the U.S. average of 4 days per year with air quality above PM2.5 limit. Oregon was ranked the worst state for having 12 days per year of air quality above PM2.5 limit.
Air and water pollution are the two most common environmental factors that can impair health. They have been linked to increased respiratory disease, gastrointestinal disorders, and other forms of illness.
Data source: 2011 U.S. Environmental Protection Agency
Source

49. Environmental Quality
Washington was ranked the best state for having 0.2% of the population exposed to water quality that was over health-based limits, while the U.S. average is 6.8 percent. Delaware is ranked the worst state for having 24.6 percent of their population exposed to water quality that was over health-based limits.
Air and water pollution are the two most common environmental factors that can impair health and lead to increased respiratory disease, gastrointestinal disorders, and other illness.
Data source: 2011 Safe Drinking Water Information System
Source

50. Environmental Quality
New York was ranked the best state for having 54 percent of their population drive alone to work, while the U.S. average is 77 percent. Alabama was ranked the worst state for having 85 percent of their population drive alone to work.
*Note: Some of these measures have question marks after the best and worst values since there is conflicting evidence suggesting that the highest and lowest values for these indicators may not necessarily represent the “best” and “worst” values for states.
Data source: 2010 American Community Survey
Source

51. Built Environment
New York was ranked the best state for having 3.7 percent of their population with limited access to healthy foods, while the U.S. average was 7.3 percent. New Mexico was ranked the worst state for having 14.8 percent of their population with limited access to healthy foods.
Health factors including access to healthy foods and participation in physical activity are directly related to features of the physical environment in which we live, learn, work and play. Additionally, the cost and quality of housing are important in terms of financial security and overall well-being.
Data source: 2006 County Health Rankings
Source

52. Built Environment
Vermont was ranked the best state with having 33 percent of restaurants classified as fast food, while the U.S. average is 49 percent. Maryland was ranked the worst state with 59 percent of restaurants being classified as fast food.
Data source: 2009 County Business Patterns
Source

53. Built Environment
North Dakota was ranked the best state with 1.1 percent of the population living in overcrowded housing, while the U.S. average was 3.4 percent. California was ranked as the worst state with 8.6 percent of their population living in overcrowded housing.
Data source: 2010 American Community Survey
Source

54. Built Environment
North Dakota was ranked the best state for having 19 percent of home-owners be cost-burdened, while the U.S. average was almost double at 38 percent. California was ranked the worst state for having 51 percent of their homeowners being considered a cost-burdened homeowner.
Data source: 2010 American Community Survey
Source

55. Built Environment
Wyoming was ranked the best state for having only 40 percent renters be of cost-burdened, while the U.S. average was 53 percent. Florida was ranked the worst state having 60.4 percent of renters be cost-burdened.
Data source: 2010 American Community Survey
Source

56. 15 measures Wisconsin scores worse than US:
Percent of homes with a smoke ban
Percent of adults that are obese or overweight
Percent of adults eating 5 servings of fruit or vegetables
per day
Percent of adults that are excessive drinkers (worst)
Percent of total population that uses seatbelts
Deaths from falls (per 100,000 population)
Median household income
Suicide rate per 100,000 population
Wisconsin has some important strengths such as a good high school graduation rate, a low percentage of cost
burdened renters, a small percentage of individuals living in overcrowded housing, a high number of children
covered by immunizations, and a low number of children without health insurance. However, Wisconsin clearly
has room to improve in many other areas such as alcohol use, tobacco use, and employment.

57. 15 measures Wisconsin scores worse than US:
Percent of total population living alone
Air quality
Percent of workers (16 and older) that drive to work alone
Personal health spending per capita
Percent of children age 3 – 4 enrolled in preschool
Percent of adults (25 and older) with a college degree
Governmental public health spending (worst)
Since there is no state that ranks best in all factors, even the healthiest state has room for improvement and can become healthier.

58. Funding for this project was provided by the UW School of Medicine and Public Health from the Wisconsin Partnership Program.
Thank you to the Wisconsin Partnership Program for providing funding for this project.

59. Contact Information University of Wisconsin Population Health Institute Department of Population Health Sciences University of Wisconsin School of Medicine and Public Health 575 WARF Building 610 Walnut Street Madison, WI