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Celebrating 35 Years
2024 marks 35 years of America’s Health Rankings®. First published in 1990, the America’s Health Rankings Annual Report provides the longest-running state-by-state analysis of the nation’s health.
Over the last 35 years, the model and measures used in the report have evolved as public health’s understanding of what drives health has advanced. In addition to looking at recent changes in today’s health, this year’s report identifies key successes and challenges experienced by populations across the country over the past three decades, highlighting public health issues that have significantly impacted communities. America’s Health Rankings will continue to provide state and national data to inform and drive action to build healthier communities.
America’s Health Rankings 35th Annual Report Provides a Holistic View of the Nation’s Health and Reveals Long-Term Trends and Short-Term Changes
The America’s Health Rankings platform offers valuable insights on the nation’s health and each of the 50 states and Washington, D.C. As a leader in public health data analysis, America’s Health Rankings has adapted its approach to measuring population health over 35 years to reflect the evolving understanding of the factors that contribute to health and well-being. Today, the model is grounded in a growing awareness of social drivers and the importance of quantifying the impact of these measures on population health.
In partnership with the American Public Health Association (APHA), the 35th Annual Report builds on the platform’s history to analyze long-term trends and short-term changes across 88 measures of health and well-being that span five categories of health. The report includes data from diverse populations, identifying areas where population-wide successes have been the result of progress made across all groups, as well as instances where disparities between groups indicate a need for focused attention.
The report details persistent challenges in health outcomes over the past decade, such as premature death, obesity, diabetes, drug deaths and depression. On the other hand, the nation has achieved significant success in reducing cigarette smoking and excessive drinking, as well as improvements in several socioeconomic and environmental factors such as air pollution.
This contrast, between worsening outcomes and improvements in certain drivers of health, underscores the complex nature of the health challenges the nation faces and compels stakeholders to think innovatively about how to improve health outcomes for different communities. Looking to the future, America’s Health Rankings encourages health leaders to use these findings to cultivate collaborative solutions that address the persistent challenges and gaps in the nation’s health and well-being, while building on successes.
“As we reflect on the findings in this year’s report, each of us who can impact health and health care in this country must rededicate ourselves to creating a healthier nation for all.” – Dr. Margaret-Mary Wilson, MD | Executive Vice President & Chief Medical Officer, UnitedHealth Group
Long-Term Success in Reducing Cigarette Smoking Nationwide Marks Significant Public Health Milestone
Smoking has significantly decreased since America’s Health Rankings began tracking the measure. Since the first Annual Report in 1990, cigarette smoking among adults has been reduced by more than half, decreasing 59% from 29.5%* to 12.1%** in 2023. Nationally, the percentage of adults who reported smoking at least 100 cigarettes in their lifetime and currently smoke daily or sometimes decreased 43% between 2011 (from 21.2%) and 2023.
Ensuring that the smoking rate continues to decrease while also addressing emerging nicotine delivery methods, such as e-cigarettes, is critical to a healthy population. Smoking is the leading cause of preventable death and disease in the United States, responsible for more than 480,000 deaths yearly, with an annual cost of premature death of $180 billion and an additional $185 billion in lost productivity. Quitting smoking can have profound benefits on current and long-term health at any age, leading to an enhanced quality of life.
Since 2011, smoking has decreased among nearly all racial and ethnic groups, as well as in 48 states** and Washington, D.C., with the greatest decreases in the District of Columbia (20.8% to 9.8%) and Rhode Island (20.0% to 9.5%). Despite this progress, in 2023, smoking varied considerably by education, race/ethnicity and geography. The prevalence of smoking was 4.8 times higher among those with less than a high school education (21.5%) compared with college graduates (4.5%). It was 4.0 times higher among American Indian/Alaska Native (21.2%) than Asian (5.3%) adults. Additionally, smoking was 3.4 times higher in West Virginia (20.4%), the state with the highest rate, than Utah (6.0%).
At the same time, e-cigarette use — the percentage of adults who reported using e-cigarettes or other electronic vaping products at least once in their lifetime and now use daily or some days — remained steady at 7.7%** between 2022 and 2023, with notable age-related disparities. E-cigarette use was 11.8 times higher among adults ages 18-44 (13.0%) compared with those age 65 and older (1.1%), the group with the lowest rate of e-cigarette use.
Mental Health Challenges Reach Unprecedented Highs Amid Rising Drug Deaths; Increase in Mental Health Providers Not Yet Meeting Demand
The U.S. continues to face behavioral health challenges, as evidenced by increases in depression, frequent mental distress and suicide. Between 2011 and 2023, the prevalence of depression among adults rose 26% from 17.5% to 22.0%, while frequent mental distress — the percentage of adults who reported their mental health was not good 14 or more days in the past 30 days — increased 32% from 11.7% to 15.4%. Suicide increased 23% between 2009 and 2022, from 12.0 to 14.8 deaths due to intentional self-harm per 100,000 population.
These mental health challenges have increased despite consistent growth in the number of mental health providers. The number of mental health providers has been consistently increasing since 2018, the first year it was reported by America’s Health Rankings. Between September 2023 and September 2024, there was a 6% increase in mental health providers — psychiatrists, psychologists, licensed clinical social workers, counselors, marriage and family therapists, and advanced practice nurses specializing in mental health care — from 325.0 to 344.9 providers per 100,000 population. The rise in mental health providers can help address these growing mental and behavioral health challenges but has yet to meet the rising demand for services. According to the Health Resources and Services Administration, growth of the behavioral health workforce is limited by a variety of challenges.
Against the backdrop of growing mental health challenges over the past decade, excessive drinking has dropped since 2011, while drug deaths have risen dramatically since 2007.
Excessive drinking often co-occurs with mental health disorders, according to the National Institute on Alcohol Abuse and Alcoholism. Between 2011 and 2023, excessive drinking decreased 16% from 19.8% to 16.7%** of adults. More than half of that decrease occurred between 2022 and 2023 — a 9% decrease in just one year. Despite this improvement, significant disparities exist between age groups. In 2023, excessive drinking was 3.3 times higher among adults ages 18-44 (22.6%) than those age 65 and older (6.9%).
Drug deaths rose sharply across the country between 2007 and 2022, rising 170% from 12.0 to 32.4 deaths per 100,000 population. During that time, the rate increased in 49 states and Washington, D.C. Those ages 65-74 faced some of the steepest increases in this period, experiencing a 375% increase (4.0 to 19.0). The largest spike at the national level occurred between 2019 and 2020, when the rate climbed 30% from 21.5 to 27.9.
Encouragingly, the overall drug death rate remained relatively stable between 2021 and 2022, although disparities persisted. Notably, the rate was 11.4 times higher among American Indian/Alaska Native (63.7) than Asian (5.6) populations.
However, non-medical drug use increased 11% between 2023 and 2024; the percentage of adults who reported using prescription drugs non-medically (including pain relievers, stimulants and sedatives) or illicit drugs (excluding cannabis) in the last 12 months rose from 15.9% to 17.6%.
Long-Term Decrease in Premature Death Reversed in Last Decade
Premature death — measured by years of potential life lost before age 75 — has been measured by America’s Health Rankings since its inception and is a key marker of overall health and well-being, according to the Healthy People 2030 framework. In 2022, the leading causes of premature death included unintentional injury (including drug overdose deaths), cancer, heart disease, suicide, COVID-19, homicide, liver disease, perinatal deaths, diabetes and cerebrovascular deaths.
In 2012, the premature death rate reached the lowest value recorded by America’s Health Rankings, the result of a 17% decrease since 1991 from 8,398 to 6,976 years of potential life lost before age 75 per 100,000 population.
However, 2012 marked a turning point. Since then, the trend has reversed, with premature death rising 22% between 2012 and 2022, reaching 9,478 deaths in 2021 amid the COVID-19 pandemic. While the most recent data show some improvement between 2021 and 2022, the overall rate of premature death (8,522) remains 1% higher than it was in 1991, erasing years of progress made between 1990 and 2012. Meanwhile, several factors that contribute to premature death continue to rise.
Homicide decreased 25% from 10.1 to 7.6 deaths per 100,000 population between 1990-1991 and 2021-2022. Rates are now rising again, and there were large disparities in the homicide rate between racial/ethnic groups and between states. In 2021-2022, the homicide rate was 20.5 times higher among Black (32.8 deaths per 100,000 population) compared with Asian (1.6) populations, as well as 14.9 times higher in Mississippi (20.9) than New Hampshire (1.4).
Diabetes and Obesity Rates Worsened Since 2011, Despite Long-Term Improvements in Clinical Care
Chronic conditions and their risk factors, which are linked to serious health outcomes including premature death, carry significant economic costs, including higher health care spending and lost productivity.
Between 2022 and 2023, the percentage of adults with multiple chronic conditions decreased 4% from 11.2% to 10.7%. However, the prevalence of some chronic conditions, such as diabetes, rose over the past decade. Between 2011 and 2023, the prevalence increased 21% from 9.5% to 11.5% of adults with disparities by income and education. Among those with an annual household income less than $25,000 (21.2%), the prevalence of diabetes was 2.4 times higher compared with those with incomes of $75,000 or more (9.0%). In addition, the prevalence was 2.3 times higher among adults with less than a high school education (21.2%) compared with college graduates (9.2%). Obesity — a risk factor for many chronic conditions — increased 23% from 27.8% to 34.3% of adults, with disparities by race/ethnicity, geography, education and income.
These health outcomes have worsened despite widespread gains in health insurance coverage rates and clinical care access over the past decade. According to the Department of Health and Human Services, lack of health insurance decreases the use of preventive and primary care services and is associated with poorer health outcomes. Primary care, including timely vaccinations, routine screenings and chronic disease management, plays a critical role in preventing illness, improving long-term health and reducing the risk of premature death.
Several clinical care measures improved over the past decade. Nationally, between 2010 and 2023, the uninsured rate decreased 49% from 15.5% to 7.9%, with decreases larger than 49% in 25 states and Washington D.C. However, disparities remain: The uninsured rate was 6.3 times higher in Texas (16.4%) than Massachusetts (2.6%) and 5.9 times higher among those with less than a high school education (20.7%) compared with college graduates (3.5%).
Meanwhile, flu vaccinations improved over the past decade, increasing 14% between 2012 and 2023, reaching 42.9%** of adults. This prevalence recently decreased 6% from 45.6% in 2022. Primary care availability also increased since 2018, with the number of active primary care providers — including general practice, family practice, obstetrics and gynecology, pediatrics, geriatrics, internal medicine, physician assistants and nurse practitioners — rising 36% from 209.0 to 283.4 providers between September 2018 and September 2024.
Improvements in Socioeconomic, Environmental Conditions That Shape Health; Long-Term Progress but Challenges Remain in Work-Related Injuries
Over the past 35 years, we've gained a deeper understanding of how social, economic and environmental conditions influence health. While this progress hasn't fully translated into nationwide improvements in health outcomes, several socioeconomic trends have improved.
Between 2013 and 2023, poverty and unemployment decreased — poverty by 14% from 14.7% to 12.7%, and unemployment by 49% from 8.4% to 4.3% of the civilian workforce. Access to high-speed internet allows individuals to fully participate in remote work, learning and health care. The 16% increase in access, from 80.8% to 93.8% of households between 2015 and 2023, represents a success across all racial/ethnic groups.
Air pollution improved over the past several decades, largely driven by regulations at the federal and state levels on emissions of toxins, as well as technological advancements. Between 2000-2002 and 2021-2023, air pollution levels — the average exposure of the public to particulate matter of 2.5 microns or less, measured in micrograms per cubic meter — decreased 35% from 13.2 to 8.6. However, there was a 4% increase from 8.3 in 2018-2020. Even with this recent rise, air pollution levels remain lower than they were in 2000-2002. Exposure to air pollution is linked to many health problems, including cancer, respiratory diseases and heart disease.
Regarding workplace safety, the rate of occupational fatalities has nearly halved since the first edition of the Annual Report, dropping 45% from 7.6 to 4.2 deaths per 100,000 workers from 1989-1991 to 2020-2022.
Despite long-term progress in occupational fatalities, the number of work-related injuries and illnesses due to heat is significantly higher in some states than others. In the U.S., heat is the leading cause of weather-related deaths. Indoor and outdoor workers exposed to extreme heat or working in hot environments are at risk for experiencing heat-related illnesses. Between 2019 and 2020, work-related injuries due to heat increased by over 10% in four states, while the rate decreased by 10% or more in 12 states.† Tennessee (1.6 cases per 10,000 full-time workers) reported the highest rate in 2020, with work-related injuries and illnesses due to heat 16.0 times higher than in the 12 states with the lowest rate of 0.1.
†Data available for 28 states. Visit the Comprehensive Report Methodology for more information about the 2020 CDC Heat & Health Tracker.
“As a nation, we are increasingly embracing evidence-based strategies in a proactive manner to address these issues via their upstream root causes. Yet, despite this momentum, many health outcomes are still moving in the wrong direction — signifying a need for stronger investments to these preventive approaches.” – Georges C. Benjamin, MD | Executive Director, American Public Health Association
“America’s Health Rankings encourages partnership by equipping public health leaders with comprehensive data, covering everything from socioeconomic and environmental factors spanning across categories, to meaningfully engage in these cross-sector conversations.” – John Wiesman, DrPH, MPH | Associate Dean for Practice and Director, Doctoral Program in Public Health Executive Leadership University of North Carolina Gillings School of Global Public Health, Chair of America’s Health Rankings Advisory Council
Call to Action
As experts’ understanding of the factors that shape health continues to grow, it is essential that how the health of our communities is measured advances as well. Data in this report and across the America’s Health Rankings platform clearly indicate that despite nationwide progress to improve some of the socioeconomic, environmental and clinical care factors that influence health and well-being, negative trends in health outcomes remain challenging, including premature death and chronic disease.
In the face of these challenges, America’s Health Rankings remains committed to providing relevant, data-driven insights that empower policymakers, advocates and leaders to view health in a broad context and take informed action that builds on successes — both nationally and at the state level, where many of the most important public health decisions are made. By harnessing the power of data, the entire public health community can collaborate to drive meaningful change, address health disparities and benefit all populations across the nation for many years to come.
Notes
*U.S. HHS, Office of the Surgeon General, Reducing the Health Consequences of Smoking: 25 Years of Progress: A Report of the Surgeon General, 1989 (data year 1985).
**Note: Values are the median of states and the District of Columbia. No data were available for Kentucky and Pennsylvania in 2023.
†Data available for 28 states. Visit the Comprehensive Report Methodology for more information about the 2020 CDC Heat & Health Tracker.