Issue Report Investing In America’s Health: A State-by-State Look at Public Health Funding and Key Health Facts March 2012 Preventing Epidemics. Protecting People. ACKNOWLEDGEMENTS TFAH BOARD OF DIRECTORS REPORT AUTHORS Gail Christopher, DN Jeffrey Levi, PhD. Trust for America’s Health President of the Board, TFAH Executive Director is a non-profit, non-partisan Vice President—Program Strategy Trust for America’s Health and WK Kellogg Foundation Associate Professor in the Department of Health organization dedicated to Policy Cynthia M. Harris, PhD, DABT saving lives by protecting the The George Washington University Vice President of the Board, TFAH School of Public Health and Health Ser- health of every community Director and Professor vices Institute of Public Health, and working to make disease Florida A&M University Laura M. Segal, MA prevention a national priority. Director of Public Affairs Theodore Spencer Trust for America’s Health Secretary of the Board, TFAH Project Manager Rebecca St. Laurent Natural Resources Defense Council Health Policy Research Manager Trust for America’s Health Robert T. Harris, MD Treasurer of the Board, TFAH Albert Lang Former Chief Medical Officer and Senior Communications Manager Vice President for Healthcare Trust for America’s Health BlueCross BlueShield of North Carolina David Fleming, MD Director of Public Health Seattle King County, Washington Arthur Garson, Jr., MD, MPH Director, Center for Health Policy, University Professor, and Professor of Public Health Services University of Virginia John Gates, JD Founder, Operator and Manager Nashoba Brook Bakery Alonzo Plough, MA, MPH, PhD Director, Emergency Preparedness and Response Program Los Angeles County Department of Public Health Eduardo Sanchez, MD, MPH Chief Medical Officer Blue Cross Blue Shield of Texas Jane Silver, MPH President Irene Diamond Fund Introduction F or too long, the country has focused on treating people after they become sick instead of preventing diseases before they occur. Investing in disease prevention is the most effective, layoffs and attrition.3 Combined state and local common-sense way to improve health — helping to public health job losses total 49,310 since 2008.4 spare millions of Americans from developing pre- LHDs continue to struggle with budget cuts. In ventable illnesses, reduce health care costs and im- July, 2011, nearly half of LHDs reported reduced prove the productivity of the American workforce budgets, which is in addition to 44 percent that — so we can be competitive with the rest of the world. reported lower budgets in November 2010.5 In addition, more than 50 percent of LHDs expect Tens of millions of Americans are currently suf- cuts to their budgets in the upcoming fiscal year. fering from preventable diseases such as cancer, heart disease and diabetes. And, today’s chil- n Differences In Federal Funding For States: dren are in danger of becoming the first gen- Federal public health spending through CDC eration in American history to live shorter, less averaged out to only $20.28 per person in FY healthy lives than their parents. 2011. And the amount of federal funding spent to prevent disease and improve health The nation’s public health system is responsible for in communities ranged significantly from improving the health of Americans. But, the pub- state to state, with a per capita low of $14.20 lic health system has been chronically underfunded in Ohio to a high of $51.98 in Alaska. for decades. Analyses from the Institute of Medi- cine (IOM), The New York Academy of Medicine n ifferences in State Funding: This report also ex- D (NYAM), the U.S. Centers for Disease Control and amined state funding and found that the median Prevention (CDC) and a range of other experts have amount in state fiscal years 2010-2011 for public found that federal, state and local public health de- health equaled only $29.80 per person, ranging partments have been hampered due to limited from a low of $3.45 per person in Nevada to a funds and have not been able to adequately carry out high of $154.80per person in Hawaii. Regionally many core functions, including programs to prevent there were large differences in state funding. disease and prepare for health emergencies.1 n ifferences In Health Statistics By State: The D In this report, the Trust for America’s Health report finds major differences in disease rates and (TFAH) examines public health funding and other health factors in states around the country. key health facts in states around the country. For instance, only 5.6 percent of residents of Mas- sachusetts are uninsured compared to almost 25 Federal funding for public health has remained percent in Texas, and less than 10 percent of at a relatively flat and insufficient level for years. adults in Utah are current smokers while almost The budget for CDC has decreased from a high 27 percent report smoking in West Virginia. of $6.62 billion in 2005 to $6.32 billion in 2011.2 There is little strategic rationale for the differences At the state and local levels, public health budgets in funding — and therefore, for the way public have been cut at drastic rates in recent years. Ac- health is funded in America. The federal funds cording to a TFAH analysis, 40 states decreased are a mixture of population-based formula grant their public health budgets from FY 2009-10 to programs, incidence or prevalence based formulas, FY 2010-11, 30 states decreased budgets for a and a series of competitive grants — where some second year in a row and 15 for three years in states receive funding and others do not. Because a row. In FY 2010-11, the median state funding of insufficient funding for the CDC, many states for public health was $30.09 per capita, ranging submit competitive grants (“approved but un- from a high of $154.80 in Hawaii to a low of $3.45 funded” applications) that cannot be awarded. But in Nevada. From FY 2008 to FY 2011, the median in most cases, there is no officially defined mode per capita state spending decreased from $33.71 or coordination for targeting or strategically focus- to $30.09. A recent study conducted by the Na- ing the funds. State and local funding varies dra- tional Association of County and City Health matically based on the structure of a state’s public Officials (NACCHO) found significant cuts to health department. Some departments are central- programs, workforce and budgets at local health ized, while others are decentralized where responsi- departments (LHDs) around the country. Since bilities rest more on local departments than at the 2008, LHDs have lost a total of 34,400 jobs due to 3 state level. However, states and localities also place public health funding should be in order to have different priorities on public health, which also ac- a real impact on reducing disease rates nationally. counts for differences in the funding. These state- Overall, the report concludes that a sustained by-state comparisons do not include county or city and sufficient level of investment in prevention revenues that are generated to support local health is essential to improving health in the United departments, which are also quite variable. States, and that differences in disease rates will This report examines some key disease rates in not be changed unless an adequate level of combination with health spending to help further funding is provided to support public health the discussion about what the right amount of departments and disease prevention efforts. Where You Live Should Not Determine How Healthy You Are Where you live, learn, work and play make a big difference in n School meals are low in nutritional value, school vending how healthy you are. machines sell junk food, and students don’t get regular physical education classes. A range of factors, like education, employment, income, family and social support, community safety and the physical environ- n ccess to fruit and vegetables is limited because there are A ment, impact our health. no supermarkets. In many communities, healthy choices are easy choices for n Dilapidated housing, crumbling schools, abandoned factories their residents. In these communities, there are plenty of and freeway noise and fumes cause illness and injury. gyms, safe places to jog and community recreation centers The poor overall conditions cause higher levels of obesity and with gleaming swimming pools and sports fields. The children chronic disease, including diabetes, heart disease and cancer, play and exercise in well maintained parks and have access leading to higher health care costs. to affordable nutritious foods. But in many other American communities, there are obstacles to healthy living: One major factor in the health of a community is whether or not they have a strong public health system. Public health n Parks and playgrounds are littered, broken, or unsafe. departments can help improve the health of communities, since n There are few places to get out and exercise — some they are responsible for finding ways to address the systemic communities don’t even have sidewalks for walking. reasons why some communities are healthier than others — and for developing policies and programs to remove obstacles that get in the way of making healthy choices possible. National Prevention Strategy and Prevention Fund The Affordable Care Act included the creation of a National Preven- 3 mprove nutrition by increasing access to fresh fruits and I tion Strategy — to set national goals and identify effective strategies vegetables and farmers markets, and helping kids to eat for improving health in the United States — and a Prevention Fund healthier meals and snacks in schools. — to provide communities around the country with more than $16 3 Expand mental health and injury prevention programs. billion over the next 10 years to invest in effective, proven prevention 3 mprove prevention services in low-income and under- I efforts, like childhood obesity prevention and tobacco cessation. served communities. n The Prevention and Public Health Fund will invest approxi- mately $13 billion over the next 10 years in proven, effec- n The Fund improves state and local health departments to: tive programs to prevent disease and injury. The Fund will: 3 Provide flu and other immunizations. 3 Bring common sense into our health care system by helping 3 Protect our food, air and water. people to stay healthy and not get sick in the first place. 3 ight infectious diseases. F 3 elp Americans to make healthier choices and take personal H responsibility for their own health and the health of their n The Fund helps modernize disease outbreak and contain- families and children. ment capabilities to: 3 educe health care costs for businesses and families; pre- R 3 Expand the workforce for public health laboratories. vent suffering; save millions of lives; keep Americans healthy 3 Provide modernized equipment and technology to labs to and at work; and improve the quality of life for all. protect us from disease outbreaks and other threats. n The Fund supports prevention efforts at the community level to: n The Fund supports science and research to: 3 educe tobacco use. R 3 Develop more and even better ways to prevent disease and 3 Expand opportunities for recreation and exercise. keep families and communities safe and healthy. 4 Funding for Public Health P ublic health programs are funded through a combination of federal, state and local dollars. Each level of government has different, but im- nificant delay from the time when a President 1 Section portant responsibilities for protecting the pub- proposes a fiscal year budget, to when appro- lic’s health. While this report focuses primarily priations legislation is signed into law, to the on federal funding to states, it also provides in- time when the funds are disbursed. Therefore, formation about state funding. TFAH uses FY 2011 data for this analysis, which is the budget year for which the data is most TFAH analyzes federal and state funding for complete and accurate. public health based on the most complete fi- nancial data currently available. There is a sig- 5 A. Federal Investment in Public Health Federal Funding for States from the U.S. Centers for Disease Control and Prevention Summary of CDC Dollars — FY 2011 State CDC Total (All Categories) CDC Per Capita Total CDC Per Capita Ranking Alaska $37,565,882 $51.98 1 Vermont $23,793,896 $37.98 2 Wyoming $18,832,635 $33.15 3 Rhode Island $34,534,605 $32.85 4 New Mexico $68,198,368 $32.75 5 South Dakota $25,352,336 $30.76 6 Montana $30,411,958 $30.47 7 North Dakota $20,450,806 $29.90 8 Delaware $25,875,080 $28.52 9 Maine $35,171,087 $26.48 10 Maryland $152,500,924 $26.17 11 Hawaii $35,197,624 $25.60 12 Mississippi $74,776,585 $25.11 13 West Virginia $45,821,729 $24.70 14 Washington $168,425,887 $24.66 15 Nebraska $45,411,154 $24.64 16 New York $473,289,511 $24.31 17 Arkansas $69,509,960 $23.66 18 Oklahoma $89,543,799 $23.62 19 Louisiana $107,864,995 $23.58 20 Georgia $228,752,481 $23.31 21 Idaho $35,630,024 $22.48 22 New Hampshire $28,832,290 $21.87 23 Massachusetts $142,233,727 $21.59 24 California $796,819,448 $21.14 25 Nevada $56,400,106 $20.71 26 South Carolina $96,384,322 $20.60 27 Texas $523,439,104 $20.39 28 NATIONAL AVERAGE $20.28 Iowa $61,380,321 $20.04 29 Alabama $95,428,398 $19.87 30 Connecticut $69,866,332 $19.51 31 Utah $54,889,856 $19.48 32 Arizona $126,192,930 $19.47 33 Illinois $250,525,016 $19.47 33 Colorado $99,303,655 $19.41 35 Kansas $52,629,741 $18.33 36 North Carolina $176,829,426 $18.31 37 Oregon $70,645,834 $18.25 38 Minnesota $96,655,652 $18.08 39 Michigan $174,382,879 $17.66 40 Kentucky $77,011,820 $17.63 41 Tennessee $112,622,362 $17.59 42 Missouri $102,906,834 $17.12 43 New Jersey $149,232,028 $16.92 44 Wisconsin $93,798,851 $16.42 45 Florida $305,261,911 $16.02 46 Pennsylvania $192,549,603 $15.11 47 Indiana $97,768,792 $15.00 48 Virginia $116,156,922 $14.35 49 Ohio $163,918,804 $14.20 50 District of Columbia $88,786,605 N/A N/A U.S. TOTAL $6,319,728,895 $20.28 NA* *D.C. was not included in the per capita rankings because it receives different funding levels than the 50 states. *Total includes monies only for Washington, D.C. and U.S. Federal public health spending through CDC av- in Alaska. The amount of funding also ranged eraged out to only $20.28 per person in FY 2011. regionally, with the Midwest averaging the low And the amount of federal funding spent to pre- of $17.65 and the West averaging the high of vent disease and improve health in communities $21.94. The Northeast and South fell into the ranged significantly from state to state, with a per middle at $20.70 and $19.91 respectively. capita low of $14.20 in Ohio to a high of $51.98 6 Federal Funding for States from the Health Resources and Services Administration Summary of HRSA Dollars — FY 2011 HRSA Per Capita Total (All State HRSA Total (All Programs) HRSA Per Capita Ranking Programs) Alaska $59,949,156 $82.95 1 Hawaii $64,454,665 $46.88 2 New Mexico $94,041,564 $45.16 3 Wyoming $23,419,069 $41.22 4 Montana $40,961,605 $41.04 5 West Virginia $75,730,030 $40.82 6 Massachusetts $256,520,190 $38.94 7 Maryland $209,561,015 $35.96 8 Rhode Island $36,593,542 $34.81 9 Maine $46,016,429 $34.65 10 Vermont $20,750,922 $33.13 11 New York $617,057,839 $31.70 12 Louisiana $144,770,300 $31.64 13 Delaware $28,615,714 $31.55 14 Washington $214,720,935 $31.44 15 Idaho $47,854,484 $30.19 16 Oregon $115,271,624 $29.77 17 Mississippi $88,436,075 $29.69 18 South Dakota $23,859,070 $28.95 19 Colorado $143,696,964 $28.08 20 Connecticut $98,247,575 $27.44 21 Alabama $126,347,908 $26.31 22 Ohio $292,343,980 $25.32 23 Arkansas $73,515,226 $25.02 24 Missouri $148,876,171 $24.77 25 South Carolina $113,727,303 $24.30 26 Illinois $309,282,921 $24.03 27 Tennessee $152,442,292 $23.81 28 National Average $23.75 North Dakota $15,227,478 $22.26 29 Kentucky $96,796,214 $22.15 30 Nebraska $40,733,955 $22.11 31 Florida $421,186,942 $22.10 32 California $827,850,412 $21.96 33 Iowa $61,751,878 $20.17 34 Pennsylvania $256,684,149 $20.14 35 Georgia $195,112,699 $19.88 36 North Carolina $181,940,453 $18.84 37 Virginia $152,245,201 $18.80 38 Arizona $121,235,587 $18.70 39 Oklahoma $70,897,793 $18.70 39 New Jersey $162,225,986 $18.39 41 Utah $50,963,666 $18.09 42 Michigan $177,946,689 $18.02 43 New Hampshire $22,335,235 $16.94 44 Texas $418,058,649 $16.28 45 Indiana $100,625,322 $15.44 46 Kansas $39,250,735 $13.67 47 Wisconsin $78,053,432 $13.67 47 Minnesota $68,959,213 $12.90 49 Nevada $34,763,422 $12.77 50 District of Columbia $139,185,860 N/A* N/A* US Total $7,401,095,538 23.75** NA** *D.C. was not included in the per capita rankings because total funding for D.C. includes funds for a number of national organizations. **The US total reflects HRSA grants to all states and D.C. 7 Health Resources and Services Administration funds are in its two largest programs, the com- (HRSA) grants to states averaged out to only munity and migrant health centers and the $23.75 per person in FY 2011. And the amount Ryan White Act HIV programs, and these dol- of funding spent for key health program areas lars are awarded on a competitive basis and/or ranged significantly from state to state, with a based on disease burden. per capita low of $12.77 in Nevada to a high of Approximately 75 percent of CDC’s budget is $82.95 in Alaska. The amount of funding also distributed to states, localities and other pub- ranged regionally, with the Midwest averaging a lic and private partners to support services and low of $20.20 and the Northeast averaging the programs. Some of CDC’s funding is based on high of $27.31. The West and South fell into the number of people in a state or on a need- the middle at $25.24 and $22.09 respectively. based formula for priority programs. Other Information on the amount of federal funding funds are based on competitive grants. States each state receives for a range of public health can apply to CDC for funding for specific pro- programs is available online at www.healthyameri- gram areas. Often in these cases, not all states cans.org along with key health facts for each state. that apply for funds receive them because there The online State Data pages contain funding in- are insufficient funds appropriated to allow all formation on programs from the U.S. Centers states to receive grants. for Disease Control and Prevention (CDC), the Public health funding from CDC has been flat Health Resources and Services Administration in recent years. After converting each year (HRSA) and the Office of the Assistant Secretary into 2011 dollars, CDC funding shows 2005 for Preparedness and Response (ASPR). A full list as the peak of distribution during the past six of the funding by category is available in Appen- years. CDC distributed $7.18 billion in 2005, dices E-F; and a list of key health statistics by state decreased significantly to $5.66 billion in 2007, is available in Appendices B-D. Notes on data and and in 2008 the amount remained flat at $5.61 methodology are available in Appendix A. billion. A slight increase in funds can be seen in HRSA distributes approximately 90 percent of 2009 and 2010 at $6.21 billion and $6.47 billion its funding in grants to states and territories, respectively. In 2011 the funds remain mostly public and private health care providers, health constant at $6.32 billion. professions training programs and other orga- Currently, most of the federal funding from nizations.6 HRSA’s funding is not distributed CDC for states is distributed by categories. on a strictly per capita basis. The bulk of HRSA WHAT ARE THE FEDERAL GOVERNMENT’S PUBLIC HEALTH OBLIGATIONS? In partnerships with states and localities, the effective response in a public health emergency federal government has an obligation to: such as a natural disaster, bioterrorism, or an emerging disease; n ssure the capacity of all levels of government A to provide essential public health services; n acilitate the formulation of public health goals in F collaboration with state and local governments n Act when health threats may span many and other relevant stakeholders; states, regions or the whole country; n Be transparent and accountable for public n Act where the solution may be beyond the health investments; and jurisdiction of individual states; n Disseminate innovation and best practices n ct to assist the states when they do not A from state and local public health. have the expertise or resources to mount an Source: Trust for America’s Health. Public Health Leadership Initiative an Action Plan for Healthy People in Healthy Commu- nities in the 21st Century.7 8 B. State Investment in Public Health State Funding for Public Health State Public Health Budgets State FY 2010-2011 FY 10-11 Per Capita Per Capita Ranking Hawaii2 $210,580,163 $154.80 1 District of Columbia4 $55,676,000 $92.53 2 Idaho $122,845,700 $78.37 3 Alaska2 $55,550,000 $78.21 4 West Virginia $132,295,059 $71.40 5 New York $1,361,874,065 $70.28 6 Vermont4 $43,951,667 $70.24 7 Alabama $335,488,409 $70.19 8 California $2,415,831,000 $64.85 9 Wyoming $33,852,718 $60.06 10 Massachusetts $350,186,952 $53.48 11 Arkansas $149,800,388 $51.37 12 New Mexico4 $105,036,600 $51.01 13 Louisiana $225,294,657 $49.70 14 Rhode Island4 $50,815,757 $48.28 15 Kentucky $192,860,700 $44.44 16 Tennessee $278,401,400 $43.87 17 Nebraska $72,785,962 $39.85 18 Washington3 $265,838,500 $39.53 19 Virginia3 $295,499,639 $36.93 20 Colorado $183,551,436 $36.50 21 Oklahoma1 $135,791,000 $36.20 22 Delaware2 $28,791,300 $32.06 23 Utah4 $84,410,000 $30.54 24 South Dakota4 $24,558,841 $30.16 25 Median $30.09 Maryland2,4 $173,747,000 $30.09 26 New Jersey $236,625,000 $26.91 27 North Dakota3 $16,939,076 $25.18 28 Montana $24,180,994 $24.44 29 Maine2 $31,434,509 $23.66 30 Florida2 $441,688,341 $23.49 31 Illinois $297,742,900 $23.21 32 Connecticut2 $79,551,713 $22.26 33 Michigan3 $205,877,200 $20.83 34 Texas $521,636,021 $20.74 35 South Carolina $81,225,679 $17.56 36 Iowa4 $51,790,348 $17.00 37 Georgia $162,837,455 $16.81 38 New Hampshire4 $21,026,483 $15.97 39 Ohio $175,566,137 $15.22 40 Kansas $43,092,255 $15.10 41 Pennsylvania2 $190,456,000 $14.99 42 North Carolina2 $132,055,198 $13.85 43 Oregon $52,141,850 $13.61 44 Indiana $83,710,931 $12.91 45 Minnesota2 $64,815,000 $12.22 46 Wisconsin $52,826,100 $9.29 47 Mississippi2 $25,875,597 $8.72 48 Arizona $54,120,500 $8.47 49 Missouri4 $35,311,567 $5.90 50 Nevada $9,307,757 $3.45 51 Notes: 1 May contain some social service programs, but not Medicaid or CHIP. 2 General funds only. 3 Budget data taken from appropriations legislation. 4 State did not respond to the data check TFAH coordinated with ASTHO that was sent out October 26, 2011. States were given until November 18, 2011 to confirm or correct the information. The states that did not reply by that date were assumed to be in accordance with the findings. 9 Forty states decreased their public health bud- The majority of funding for public health comes gets from FY 2009-10 to FY 2010-11, 30 states from the state and local levels, although estimates decreased budgets for a second year in a row, 15 of the percentages vary. In 2000, according to for three years in a row. In FY 2010-11, the me- one analysis, state and local spending was 2.5 dian state funding for public health was $30.09 times the federal level, accounting for 70 percent per capita, ranging from a high of $154.80 in of all public health spending.8 According to this Hawaii to a low of $3.45 in Nevada. From FY analysis, in 2000, combined state and local public 2008 to FY 2011, the median per capita state health spending was $44.29 per person while fed- spending decreased from $33.71 to $30.09. eral spending was $17.77 per capita. Dramatic cuts to state and local funding since 2008 mean this ratio is likely to change significantly. WHAT ARE STATE AND LOCAL GOVERNMENTS’ PUBLIC HEALTH OBLIGATIONS? States and localities have an obligation to: also be publicly available and utilized by public health departments to work collaboratively n ulfill core public health functions such as F with hospitals, physicians and others with a diagnosing and investigating health threats, role in public health to set health goals; informing and educating the public, mobilizing community partnerships, protecting against n Work collaboratively with the multiple natural and human-made disasters and stakeholders who influence public health at enforcing state health laws; the community level in designing appropriate programs and interventions that address key n Provide relevant information on the com- health problems and improve the health of munity’s health and the availability of essen- the region; and tial public health services.  This information should be integrated with reporting from local n Deal with complex, poorly understood hospitals and health care providers to show problems by acting as “policy laboratories.” how well public concerns and health threats States and localities are closer to the people are being addressed. These reports should and to the problems causing ill health. Trust for America’s Health. Public Health Leadership Initiative an Action Plan for Healthy People in Healthy Communities in the 21st Century.9 10 C. Local Investment in Public Health There are approximately 2,800 local health de- single primary care physician was $202,392 in partments in the United States serving a diverse 2010 — as a result, 27 primary care physicians assortment of populations ranging from less would cost nearly $5.5 million, or more than than 1,000 residents in some rural jurisdictions 27 times the public health investment.12 to around eight million people, as in the case According to a 2008 study by researchers at the of the New York City Department of Health.10 University of Arkansas for Medical Sciences, while Local health departments are structured dif- local public health spending reached $29.57 per ferently in each state and may be centralized, capita for the median community in 2005, fund- decentralized or have a mixed function. There- ing ranged from an average of $8 per person in fore, the level of responsibility and services the lowest 20 percent of communities to nearly provided by LHDs varies dramatically, and, cor- $102 per person in the top 20 percent of com- respondingly, the way resources are determined munities.13 The spending in the top 20 percent and allocated differs significantly. was 13 times more than the lowest 20 percent. A July 2011 study published in the journal They found that communities in the top quintile Health Affairs found that increased spending of public health spending were likely to operate by local public health departments can save as decentralized units of government. lives currently lost to preventable illnesses.11 In addition, the researchers found that commu- Researchers Glen P. Mays and Sharla A. Smith nities with higher rates of medical spending and mapped spending by local public health agen- resources and more physicians per capita spent cies from 1993-2005 with preventable mortality less on public health, and conversely communi- rates in each agency’s respective jurisdiction. ties with lower rates of medical spending and The report found: resources and numbers of physician spent more n n average, local public health spending rose O on public health. The authors provide possible from $34.68 per capita in 1993 to $40.84 per reasons for this, including that: communities that capita in 2005 — an increase of more than spend a lot on medical care may not have addi- 17 percent. tional resources for public health; that commu- nities with low rates of health insurance may rely n or each 10 percent increase in local public F more strongly on public health services for their health spending, there were significant de- needs; and communities with good preventive creases in infant deaths (6.9 percent drop), services may offset the need for medical care.14 deaths from cardiovascular disease (3.2 percent drop), deaths from diabetes (1.4 percent drop) NACCHO found significant cuts to programs, and deaths from cancer (1.1 percent drop). workforce and budgets at local health depart- ments around the country. Since 2008, LHDs n he 3.2 percent decrease in cardiovascular T have lost a total of 34,400 jobs due to layoffs disease mortality cited above required local and attrition.15 Combined state and local pub- health agencies to spend, on average, an lic health job losses total 49,310 since 2008.16 additional $312,274 each year. In contrast, LHDs continue to struggle with budget cuts. achieving the same reduction in deaths In July, 2011, nearly half of LHDs reported re- from cardiovascular disease by focusing on duced budgets, which is in addition to 44 per- treatment and other traditional health care cent that reported lower budgets in November approaches would require an additional 27 2010.17 In addition, more than 50 percent of primary care physicians in the average met- LHDs expect cuts to their budgets in the up- ropolitan community. To put this compari- coming fiscal year. son in perspective, the median salary for a 11 2 Section Key Health Facts Adult Health Indicators % Uninsured, All Ages (2010) Adult Physical Inactivity Rate 2008-2010 AIDS Cum Cases 13 and Older 2009 U.S. Total 16.3% N/A 1,099,163 State with Highest/ Worst Texas (24.6%) Mississippi (32.6%) New York (199,433) State with Lowest/ Best Massachusetts (5.6%) Minnesota (17.6%) North Dakota (184) Alzheimer’s Estimated Cases among 65+ (2025) 6,479,700 California (660,000) Alaska (7,700) Asthma 2010 13.5% Hawaii (17.6%) Tennessee (9.3%) Percent Exclusive Breastfeeding at 6 Months, 14.8% West Virginia (5.6%) California (25.7%) Births 2008 Cancer Estimated New Cases — 2011 1,596,670 California (163,480) Wyoming (2,680) Chlamydia Rates per 100,000 Population (2010) 426.0 D.C. (932.0) New Hampshire (185.9) Diabetes 2008-2010 N/A Alabama (12.2%) AK and CO (5.9%) Fruits and Vegetables 2005-2009 N/A Oklahoma (15.5%) D.C. (32.1%) Human West Nile Virus Cases 2011 667 California (154) N/A Hypertension 2005-2009 N/A Mississippi (34.8%) Utah (20.3%) Obesity 2008-2010 N/A Mississippi (34.4%) Colorado (19.8%) Pneumococcal Vaccination Rates 65 and Over 2010 68.8% Illinois (61.9%) Oregon (74.0%) Poverty 2006-2008 12.7% Mississippi (20.5%) New Hampshire (6.1%) Seasonal Flu Vaccination Rates 65 and Over 2010 67.5% Nevada (59.3%) Colorado (73.4%) Syphilis Rates per 100,000 Population (2010) 4.5 D.C. (22.3) Wyoming (0.0) Tobacco Use -Current Smokers 2010 17.3% West Virginia (26.8%) Utah (9.1%) Tuberculosis Number of Cases — 2010 11,182 California (2,327) Vermont (5)  CHILD HEALTH INDICATORS % Uninsured, under 18 (2010) 9.8% Nevada (17.5%) Hawaii (2.3%) AIDS Cumulative Cases Under Age 13 — 2009 9,448 New York (2,438) ND and WY (2) Yr End Asthma — 2009 High School Students 21.7% Hawaii (28.3%) South Dakota (15.5%) Fruit and Vegetable Indicator — 2009 18.4% North Dakota (13.7%) Colorado (24.4%) % of Kids 19 to 35 Months w/out All 29.8% Idaho (42.6%) New Hampshire (19.0%) Immuniz’s-2010 Infant Mortality — Per 1,000 Live Births, 2008 6.6 D.C. (10.9) New Hampshire (4.0) Final Data % Low Birthweight Babies — 2009 Final Data 8.2 Mississippi (12.2%) South Dakota (5.8%) Obese — 2009 High School Students N/A Mississippi (18.3%) Utah (6.4%) Obese: % of 10 to 17 Year Olds — 2007 N/A Mississippi (21.9%) Oregon (9.6%) Pre-Term Births % of live births 2009 Final Data 12.2% Mississippi (18.0%) Vermont (9.3%) Tobacco: Current Smokers High School N/A Kentucky (26.1%) Utah (8.5%) Students 2009 12 The following are a series of maps demonstrating differences in disease rates for a number of key indicators on a state-by-state basis. Adult Asthma Rates WA ND MT MN VT ME SD WI OR ID NH WY MI NY IA MA NE PA RI IL IN OH CT NV UT NJ CO KS MO WV DE KY VA MD DC CA OK TN NC NM AR AZ SC MS AL GA TX LA Asthma Rates, % Adults (2010) PR n <11% FL n <13% AK n <14% HI n <16% n <18% n N/A Asthma 2010 data come from the BRFSS Prevalence Data 2010, percent responding “ever been told” they have asthma. National Center for Chronic Disease Prevention & Health Promotion, Centers for Disease Control and Prevention. Available at BRFSS Data Asthma Rates, High School Students WA ND MT MN VT ME SD WI OR ID NH WY MI NY IA MA NE PA RI IL IN OH CT NV UT NJ CO KS MO WV DE KY VA MD DC CA OK TN NC NM AR AZ SC MS AL GA Asthma 2009 LA TX High School Students  PR n <6% FL AK n <11% HI n <17% n <23% n <28% n N/A Asthma 2009 High School Students data come from the Youth Risk Behavior Surveillance System, Comprehensive Results 2009, percent responding “ever been told” they have asthma. National Center for Chronic Disease Prevention & Health Promotion, Centers for Disease Control and Prevention. Available at:http://www.cdc.gov/mmwr/pdf/ss/ss5905.pdf (accessed October 19, 2010). 13 Immunization Gap Among Children ages 19 to 35 months WA ND MT MN VT ME SD WI OR ID NH WY MI NY IA MA NE PA RI IL IN OH CT NV UT NJ CO KS MO WV DE KY VA MD DC CA OK TN NC NM AR AZ SC MS AL GA TX LA Immunization Gap: Children Aged 19 to PR 35 Months without FL All Immunizations AK (2010)  HI n <24% n <28% n <33% n <38% n <43% n N/A Immunization Gap: Children Aged 19 to 35 Months without All Immunizations 2010 data come from Estimated Vaccination Coverage with Individual Vaccines and Selected Vaccination Series Among Children 19-35 Months of Age by State and Local Area U.S., National Immunization Survey, 2010 (ac- cessed November 3, 2011). TFAH used the data for the 4:3:1:3:3:1 series which is the CDC-recom- mended series for children aged 19--35 months. The 4:3:1:3:3:1 series is used to evaluate progress toward one of the Healthy People 2020 objectives, which aims to achieve greater than 80% coverage with the series among children ages 19--35 months. 14 Percent of current adult Smokers WA ND MT MN VT ME SD WI OR ID NH WY MI NY IA MA NE PA RI IL IN OH CT NV UT NJ CO KS MO WV DE KY VA MD DC CA OK TN NC NM AR AZ SC MS AL GA TX LA Tobacco Use — Current Smokers PR (2010)  FL n <13% AK n <16% HI n <20% n <23% n <27% n N/A Tobacco Use - Current Smokers 2010 data come from the BRFSS Prevalence Data 2010, percent re- sponding they are current smokers. National Center for Chronic Disease Prevention & Health Promotion, Centers for Disease Control and Prevention. Available at BRFSS Data. Percent of high school student smokers WA ND MT MN VT ME SD WI OR ID NH WY MI NY IA MA NE PA RI IL IN OH CT NV UT NJ CO KS MO WV DE KY VA MD DC CA OK TN NC NM AR AZ SC MS AL GA Tobacco: Current LA TX Smokers High School Students PR (2009)  FL AK n <5% HI n <10% n <16% n <21% n <26% n N/A Tobacco: Current Smokers High School Students 2009 data come from the Youth Risk Behavior Surveillance System, Comprehensive Results 2009,percent of “students who smoked cigarettes on one or more of the past 30 days.” National Center for Chronic Disease Prevention & Health Promotion, Centers for Disease Control and Prevention. Available athttp://www.cdc.gov/mmwr/pdf/ss/ss5905.pdf (accessed October 19, 2010). 15 Infant mortality per 1,000 live births WA ND MT MN VT ME SD WI OR ID NH WY MI NY IA MA NE PA RI IL IN OH CT NV UT NJ CO KS MO WV DE KY VA MD DC CA OK TN NC NM AR AZ SC MS AL GA TX LA Infant Mortality per 1,000 Live PR Births (2008) FL n <5 per 1000 AK n <7 per 1000 HI n <8 per 1000 n <10 per 1000 n <11 per 1000 n N/A Infant Mortality per 1,000 Live Births 2008 data come from the National Center for Health Statistics, National Vital Statistics Report, Deaths: Final Data for 2008 (accessed January 3, 2012). PNEUMOCOCCAL VACCINATION RATES, 65 AND OVER WA ND MT MN VT ME SD WI OR ID NH WY MI NY IA MA NE PA RI IL IN OH CT NV UT NJ CO KS MO WV DE KY VA MD DC CA OK TN NC NM AR AZ SC MS AL GA TX LA Pneumococcal Vaccination Rates, 65 and Over (2010) PR FL n <64% AK n <67% HI n <69% n <72% n <74% n N/A Pneumococcal Vaccination Rates 65 and Over 2010 data come from the BRFSS Prevalence Data 2010.  National Center for Chronic Disease Prevention & Health Promotion, Centers for Disease Control and Prevention.  Available atBRFSS Data 16 Examples of Prevention in Action Prevention in Action 3 Section Travis County and Austin City Limit Tobacco Use By Philip Huang, MD, MPH, Medical Director/Health Authority at City of Austin I n Travis County, tobacco is the number one preventable cause of death; it is estimated that 11 people die each week in Travis County from tobacco-related disease. Tobacco kills that persons with serious mental illness are two to four times more likely to develop a nicotine addiction, consume nearly half of the cigarettes sold in the United States, and have a 25-year more than AIDS, crack, heroin, cocaine, alcohol, fires, car acci- shorter life expectancy than the rest of the general population. dents, suicides and murder combined. To prevent the chronic ATCIC heard from their clients that they really didn’t want to and deadly conditions that come from tobacco use, Travis be smoking; they just smoked because everyone else was and County and the City of Austin focused on policies and programs they were bored. The policy changed the environment: ciga- that would shift the population and environment away from to- rettes were once seen as rewards for positive behaviors, but bacco use and ensure long-term sustainability and positive gains. now the entire center is tobacco-free, healthier and even more successful in dealing with all of their clients’ addictions. Since the city already had a strong clean indoor air ordinance, we looked to go beyond smoke-free and address tobacco-free In addition, there is support for tobacco-free policies in worksites campuses and outdoor areas. To obtain community involve- and universities. The Mayor’s Fitness Council has a certification ment, we partnered with a large coalition that included mem- program that rewards employers that promote healthy behaviors, bers from the business community, healthcare providers, local including physical activity, good nutrition and tobacco-free policies. foundations, schools and universities, local non profits, and city After tobacco-free policies were implemented at participating and county agencies. companies, some of the most vocal employees who had initially been opposed to the tobacco-free policies sent thank you e-mails From a clinical standpoint, we worked with the Integrated detailing how they quit smoking because of the policies and how it Care Collaboration, a coalition of local indigent care providers changed their lives. At Dell Computer, smoking rates went from including the Federally Qualified Health Centers. These efforts 13 percent to three percent — very few interventions can have modified electronic health records to ensure every patient that kind of impact on behavior. Quite simply, going tobacco-free was assessed for tobacco use and offered cessation services at workplaces promotes healthy behaviors and can prevent health at every visit. We also challenged these groups to adopt 100 consequences and save healthcare dollars down the line. percent tobacco-free campus policies — not just smoking, but chewing tobacco and other forms as well. We found that there As we were working to limit outdoor tobacco use, we also was very little perceived difference between tobacco-free and began to look at our parks. Texas has been in extreme drought, smoke-free, so it’s far easier to start with the more encom- and in September, 2011, we had the most catastrophic fire in passing tobacco-free initiatives. Collaborators on this project Texas history just outside of Austin in Bastrop. Partnering with include Seton Family of Hospitals, Lone Star Circle of Care, the Parks and Recreation Department, we were able to get Central Health (Travis County Healthcare District), CommU- the media to warn people about tobacco-use in parks and the nity Care, El Buen Samaritano and Peoples Community Clinic. potential for setting fires. Because of a burn ban in place, for the first time ever, the Austin City Limits Music Festival was One of our own employees was dramatically impacted by the officially smoke-free. Then, in December 2011, the Austin City Seton Family of Hospitals smoke-free campus policy when she Council passed a smoke-free park ordinance. was caring for her husband at Seton after he was diagnosed with lung cancer. After over 40 years of smoking, she finally Through all our initiatives, we’ve found that if you give quit because of the inconvenience of having to walk across the communities and leaders resources and information, they can street to smoke. She found that she saved thousands of dollars make impactful changes and prevent illness down the road. and was able to give up smoking after just two weeks of trying. Our work is by no means complete, we still need tobacco- free policies for multi-unit housing and restaurant and bar Austin/Travis County Integral Care (ATCIC), the local mental patios, but we know our community is an engaged and active health and substance abuse authority, was one of the first in our participant in this movement. community to adopt a tobacco-free campus policy. Data shows 17 Prevention in Action The Dudley Greenhouse: Fresh Produce in the City By Lisa Conley, Director of Intergovernmental Relations & Public Health Advocacy, Boston Public Health Commission W e all know that consumption of fruits and vegetables protects us from obesity as well as an array of chronic diseases, including greenhouse, leased the facility to The Food Proj- ect (TFP) in 2010. Building on its many years of nurturing green spaces in surrounding neighbor- cancer, diabetes and cardiovascular disease. Yet, hoods, and with the resources provided by Bos- in spite of these known health benefits, many ton’s Communities Putting Prevention to Work Boston residents do not eat the recommended grant, TFP was able to undertake the final steps minimum five daily servings of fruits and needed to get the space into working order. vegetables. Fewer than a third (28%) of Boston’s The greenhouse measures approximately 10,000 adults and fewer than one-fifth (18%) of public square feet. Its growing space has been orga- high school students consumed fruits and nized into four bays with one additional smaller vegetables at this minimum level. For too many bay that houses the controls, storage and edu- of Boston’s low-income residents, affordable fresh produce is cational and vegetable washing spaces. Two of the growing simply not accessible. bays will be dedicated for use by the community (“community Increasing access to urban gardening opportunities is an inte- bays”), with the remaining two (“enterprise bays”) allocated gral strategy to both bolster healthy eating among low-income to growing produce to be sold at market rate to restaurants residents and to increase physical activity through gardening. and other business. The goal is to generate enough revenue Research on school gardens demonstrates that participa- to enable this valuable community learning resource to be fi- tion in gardening and urban agriculture can encourage fruit nancially self-sufficient. and vegetable consumption among children, and has led to Spinach, tomatoes and salad greens are just some of the vege- increased physical activity and improved nutrition among low- tables that are grown and harvested in the greenhouse. When income populations of color. With this in mind, the Boston the greenhouse is in full production, the bays are expected Public Health Commission partnered with the Dudley Street to generate a yield ranging from 30,000 to 40,000 pounds of Neighborhood Initiative (DSNI) and The Food Project (TFP) fresh produce per year, depending on the varieties of veg- to rehabilitate a 10,000 square foot greenhouse in the heart of etables planted. The community bays are used by community Boston’s Roxbury neighborhood. organizations to grow vegetables for their members. In addi- Located at 11 Brook Avenue, the greenhouse replaced the for- tion, community bay produce may be donated to local hunger mer Brook Avenue Garage, a dilapidated structure that had lain relief organizations, serve as material for classes on cooking dormant for many years. Not only were the physical remains healthy meals, or be sold at neighborhood farmers’ markets/ of this abandoned mechanic’s shop a neighborhood eyesore, stands at substantially reduced prices. The prospects are but the site also posed serious environmental hazards, owing many, and what is most exciting is that these decisions will to the nature of the business that had been run there. In prep- be made with significant input from the community that the aration for the greenhouse’s construction in 2004, the Mass greenhouse will serve. Highway Department conducted extensive environmental site “Not too long ago, this site where we’re standing was a ga- assessment, investigation and remediation.18 The remediation rage; it was a blight on the neighborhood,” Mayor Menino said effort brought down lead and other industrial contamination to during a visit to the Dudley Greenhouse in August. “Now it is below acceptable levels. an agricultural oasis, where residents can learn how to grow After several attempts to develop business projects to ben- their own vegetables, and where fresh, affordable produce efit the community, DSNI, which remains the owner of the will be grown for the city’s farmers’ markets and food banks.” 18 Prevention in Action Smoke-Free Environments: Helping Bostonians Breathe Easier at Home, Work and Play By Lisa Conley, Director of Intergovernmental Relations & Public Health Advocacy, Boston Public Health Commission I n 2004, Boston was one of the first cities in the nation to ban smoking in the workplace, a decision that Mayor Menino calls one of the ing indoor air quality for the housing authority’s 27,000 residents and 900 employees. Beyond indoor air policies, the city has imple- toughest fights of his career. “I remember we mented policies to improve outdoor air quality announced that policy on Valentine’s Day at in targeted environments. This past summer, Doyle’s Pub in Jamaica Plain,” the Mayor recalls the Parks Department posted No Smoking signs fondly, “I love Doyle’s, but I wasn’t sure I was at all 135 city-owned playgrounds, urging par- going to get out of there alive that day. I did, ents and park users to think twice before light- but I didn’t go back for a few months.” What ing up around young children. was a controversial policy in 2004 is now un- derstood to be one of the most effective public And this fall, the Mayor stood with the city’s health interventions in the last decade. teaching hospitals to announce a plan to make city hospital campuses smoke free. When fully imple- Now, Boston is again on the cutting edge of to- mented in April 2012, these policies will eliminate bacco prevention, thanks to the leadership of the secondhand smoke exposure during over 5 mil- Mayor and an infusion of federal funding from lion patient visits and for over 50,000 employees. the Centers for Disease Control and Preven- “Hospitals are places where sick people go for tion’s (CDC) Communities Putting Prevention to healing,” said Dr. Paula A. Johnson, a cardiolo- Work Program. The Boston Public Health Com- gist who is executive director of the Connors mission (BPHC) received $6.1 million to reduce Center for Women’s Health and Gender Biology Boston residents use and exposure to tobacco. at Brigham and Women’s Hospital, and chair of Over the past two years, this funding has been the Boston Public Health Commission’s Board used to support a robust campaign to implement of Health.  “It is critically important that hospitals smoke-free policies throughout the city, includ- create environments — not only inside the walls ing in public and private housing, on hospital of the institutions, but also on their doorsteps — campuses and on all public school properties. that promote good health.” In 2010, BPHC, in partnership with private de- The city followed up the hospital announcement velopers and city development agencies, set out with a vote of the Boston School Committee, in to create 1,000 new smoke-free housing units January 2012, which passed a comprehensive to- by providing technical assistance, free advertis- bacco and nicotine free policy in all public schools. ing and other incentives to building owners. The policy includes a tobacco free buffer zone The city has now far-exceeded its goal, with of 50 feet around school property and additional over 4,000 units logged in the last two years. In enforcement and signage. This policy protects addition, the Boston Housing Authority will con- 56,000 students and 9,000 staff at 135 schools. vert its 12,000 units to be smoke-free, improv- 19 Prevention in Action Dane County: Linking Our Local Food System with the Health of our Community By Carrie Edgar, Department Head and Community Food Systems Educator, Dane County UW Extension D ane County UW-Extension has a long history of working with the farmers who raise our food and the consumers who purchase nutrition and other important life skills. Our goal is to have a garden at every school in the county. Extension staff were founding members of the it. However, through Community Food Systems GROW Coalition that supports school and par- work, we have broadened that goal to ensure ent organizations that are interested in outdoor our local food system encompasses all members education with a strong emphasis on nutrition of the community (rural and urban) and has pub- and getting kids outside and active. lic health and prevention as a priority. This shift Since 2005 the Dane County Food Council, a com- has coincided with the local food movement. mittee of citizens and County Board Supervisors, In Dane County, which includes Madison, has led the mission to explore issues and develop Wisconsin, we are lucky to have a diverse recommendations to create an economically, so- agriculture system. Along with conventional row cially and environmentally sustainable local food crop farming, we have many fruit and vegetable system for Dane County. They have advocated for farms, Community Supported Agriculture farms, policies and supported the development of pro- and livestock and dairy farms. We also have grams within the county such as the Institutional multiple farmers markets and in fact, our Dane Food Marketing (IFM) Coalition. The Coalition County Farmer’s Market is the largest producer- started in 2006 to link farmers with schools, hos- only market in the country. pitals and other institutions to help them source local food. We found many organizations want to Still, when we took a step back and looked at purchase locally grown food, however they didn’t the entire community, we realized not everyone have the channels to do so efficiently. IFM connects had access to fresh, locally grown food. Solv- farmers with the institutions, improving the farmer’s ing this type of disparity became a priority and business and the health of the community members many members of the community, including these organizations employ, teach and serve. To our local government, took up the issue. Some of knowledge, this is the only County operated coali- the most notable improvements have been the tion of its kind that exists in the United States and it development of school and community gardens, has had tremendous success. IFM generated more implementation of farm to school programs and than $1.5 million in local wholesale food sales in the expansion of farmers markets. 2010 helping to create or retain 29 jobs in the area. In an effort to provide place-based education, We are also working to address barriers in the Dane County UW-Extension nutrition educators community food system that have been identified set-up displays at farmers markets to talk to peo- including lack of infrastructure and farmer access ple about what produce is in-season and inex- to land. One of these new projects is the develop- pensive and to provide cooking demonstrations. ment of a food hub (produce packing house) where Often, we find that people are interested in using locally grown produce can be aggregated, packed fresh ingredients but thought they were too and sold to local distributors and institutions. We expensive or didn’t know how to prepare them. are also working with the Dane County Parks The nutrition educators are often stationed at Department on ways to make county owned land markets near public health clinics and help peo- available to beginning farmers to raise food. ple understand that they can use their Women, Infant and Children (WIC) coupons and EBT card In Dane County, we are working to help every for food benefits at the farmers market. member of the community stay healthy and be active, so our community can thrive. By engaging Extension also works closely with schools and with people at various levels, we ensure healthy other organizations to help create and main- foods and information is available to all who tain school gardens. We use school gardens as want to live healthier and more active lives. classrooms to teach students about gardening, 20 Prevention in Action Shifting the Wellness Culture: Making the Healthy Choice the Easy Choice By Kay Owen, HEALTHY Armstrong Project Director I n 2005, Pennsylvania began to require that schools measure Body Mass Index (BMI) of students and send letters to parents of over- building, there is a wellness facilitator who plans and implements in-school and after school activities that are either physical or include weight or obese children. At the same time, a lessons about nutrition. Also, every secondary local pediatrician noticed that a significant por- school has a morning walking program — so tion of his pediatric patients had conditions that when kids arrive, instead of standing around, used to be adult problems (high blood pressure they have walking clubs and each elementary and cholesterol levels, sleep apnea and obesity). school has morning exercises that are announced over the loudspeaker. He began to talk with the local hospital about this and they brought in other members of the com- We’ve received positive feedback from many munity, including the local school district. Later, members of the community. One mother wrote the county government and a commercial insurer to us detailing her experience with her daugh- got involved. As time went on, others were ter. She said, my child was considered fat, but added to the group such at the YMCA, 4-H, local once we acknowledged the issue, we took steps recreational groups, businesses and parents. to address the problem. The whole family par- ticipated in helping her lose weight and we all In the past, when we looked at the older BMI look better and feel better. At first it was hard data, we realized a large portion of children enter- to break bad habits, but we drew upon commu- ing kindergarten were within the normal weight nity services and are much happier. range, but, as they went through elementary school, their BMIs went up before plateauing in The work we’ve done with schools and families high school. More recently, we noticed that kids has spread throughout the community. In the entering kindergarten were now overweight and summer, the hike and bike event draws tons obese, so we shifted to focus on birth to school of interest. In addition, our Healthy Lifestyle age and added more of a family/community focus. Extravaganza, which is held at the local vocational education school, includes exercise Making the Healthy Choice the Easier Choice stations. At the event, kids rotate from station In schools, we removed all vending machines that to station and obtain tickets and the tickets are contained junk food and sugary beverages from turned in for door prizes. There is also a healthy student areas and replaced them with healthy ma- cooking demonstration by the culinary students: chines. In addition, we no longer have deep fryers where students learn how to make healthy in our schools and sell nothing fried. While we do snacks and then get to eat them! serve a form of fries, they are baked and are served les frequently. Instead, we provide fruits and veg- We have dramatically shifted the culture in etables at every single meal and we also use only our schools and community. In October of whole grain products and serve 1% and skim milk. 2006, kids in the Armstrong School District participated in 402,142 minutes of physical ac- In the first few years, the school district in- tivity. Two years later, students participated in creased the amount of fresh fruit and vegetables 796,260 minutes of physical activity. purchased by more than $50,000 per year.  In 2003, the school district purchased $61,930 By focusing on the entire community, we can worth of fresh fruits and vegetables. In 2006, help children and families strive to be healthier. that figure more than doubled to $136,197. Our story shows that if you provide the re- sources and tools, families know what to do In addition to changing the food that’s available, with them. We all want to be healthy and happy, we had to shift the culture. At each school sometimes we just need a little help. 21 Prevention in Action De-Normalizing Smoking and Preventing Tobacco Related Illnesses By Linda Aragon, Program Director, Tobacco Control and Prevention Program at Los Angeles County Department of Public Health S ince its inception in 1989, the Los Angeles County Tobacco Control and Prevention Program (TCPP) has gained valuable experience 5. Policy implementation and enforcement: work with city officials to ensure adequate resources are created to support the imple- in the field of tobacco control and continues to mentation and enforcement of local policies. evolve in order to tackle the complexities and In addition to developing this organizing tool, challenges of implementing a successful tobacco TCPP implemented infrastructural changes that control program. Following the lead of the state enabled the program to strengthen community tobacco control program, TCPP transitioned partnerships, provide quality technical assis- from a health education approach focusing on tance, and build internal and external capacity individual-level behavior change to a policy-based to work with community-based organizations to approach targeting community-level social norms. spearhead local tobacco control activities. As TCPP changed processes, we had to develop Short-term and intermediate outcomes, includ- different and new capacities. To do so, TCPP col- ing the number of tobacco control policies laborated with The Center for Tobacco Policy & adopted in Los Angeles County cities and the Organizing (The Center) to develop a step-by-step unincorporated areas and the prevalence of approach that could be used by community part- cigarette smoking and exposure to secondhand ners to plan and implement their work. The Policy smoke exposure have been collected, and long- Adoption and Implementation model is separated term outcomes are currently being evaluated. into five distinct phases that build upon each other: However, we have found that tobacco control 1. Community assessment: identify the policies, which are part of a comprehensive problems and develop an understanding of tobacco control program, change social norms what is needed to address the issue; around smoking, reduce smoking prevalence 2. olicy strategy development: use information P and increase quit attempts. from phase I to build an action plan; To date, more than 50 cities and the Los Angeles 3. Coalition building/broadening: increase County Board of Supervisors, which governs the public awareness about efforts to address unincorporated areas of the county, have en- tobacco problem in a community; acted one or more tobacco control policies. The adoption and implementation of these policies 4. mplementation of policy strategies: work I create a level playing field for affected businesses with communities to educate and inform local and provide increased protection from the harm- officials about the impact of tobacco use and ful effect of secondhand smoke exposure. exposure to secondhand smoke; and 22 Prevention in Action Live Well, San Diego!: Building One of the Nation’s Most Thriving Counties By Nick Macchione, FACHE, Director and Deputy Chief Administrative Officer, Health and Human Services Agency, County of San Diego, California A sk any given person what immediately comes to mind when they think of San Diego, and you’ll likely get a response about its for the entire region. The first part of the plan was adopted by the County Board of Supervi- sors in July 2010 and focuses on Building Better role as a vacation destination, with its plenti- Health.21 The Building Better Health compo- ful beaches, mountains and desert landscapes; nent of Live Well, San Diego! has four key goals: its incredible weather; its friendly residents; its 1) Building a Better Service Delivery System for robust military presence; or its role as a key cor- the over 600,000 San Diegans we serve each ridor for commerce. Sunny San Diego County year; 2) Supporting Positive Healthy Choices bustles year-round with activity, ranging from by all San Diegans; 3) Pursuing Policy and Envi- Navy SEAL trainings to weekly charitable walk- ronmental Changes by supporting sustainable athons. With all that San Diego has to offer, policy and environmental improvements; and 4) a logical conclusion would be that San Diego Changing Culture From Within County Govern- County residents are healthy and thriving. ment by promoting employee wellness.22 The second and third parts of the plan are referred Unfortunately, the reality is that one out of to as “Living Safely” and “Thriving,” and both every two San Diego adults is overweight or are currently being developed to synergize with obese. To make matters worse, nearly one- our Building Better Health strategy. third of all fifth, seventh and ninth graders are overweight or obese. In other words, San It’s a decidedly ambitious plan that requires ac- Diego is as physically unfit as any other geo- tive involvement from the entire region. We are graphical region of our nation. The County of engaging San Diegans of all ages—from school- San Diego, Health and Human Services Agency aged children to seniors—and from all walks of (HHSA) recently identified a looming health life—from teachers to farmers to military of- “tsunami” that, absent any action, is poised to ficers to philanthropists to community leaders. hit our shores. We refer to this major threat as We’re also reaching out to entities in all sec- “3-4-50,” noting that three behaviors (poor diet, tors—ranging from governments to businesses lack of physical activity, and smoking) contribute to faith-based organizations to health and social to four chronic diseases (heart disease/stroke, service providers to life science and biotech cancer, Type II diabetes, and lung disease) that innovators. The goal is to create community cause over 50 percent of all deaths in the re- convergence by establishing “Accountable Care gion.19 The statistics are sobering: over 4 billion Communities,” in which all members of our dollars are spent each year in San Diego County communities are working together to establish to treat these four chronic diseases alone.20 community-wide health goals and measure their performance against those shared goals. However, the County of San Diego is not willing to allow the area that boasts America’s Finest One surprising—and tremendously encourag- City to continue down this destructive path. ing—development has been that the business In 2010, the County set out to make a major community has turned out to be one of the most course correction and rolled out a regional ef- enthusiastic supporters of Live Well, San Diego! fort to steer San Diego away from a state of We have found that a major draw of Live Well, San chronic disease and spiraling health care costs, Diego! is that it offers the business community an and towards a future in which all San Diegans opportunity to achieve what we at the County call are healthy, safe and thriving. The ten-year “a healthy bottom line.” The idea is that supporting roadmap to help us get there is known as, “Live healthier lifestyles will lead to healthier families and Well, San Diego!” It’s a three-part plan that employees, and lower health care expenditures by harmonizes health, safety and economic vitality keeping chronic conditions at bay. 23 Prevention in Action continued Live Well, San Diego! There are many ways in which the business com- HHSA has piloted a Care Transitions Interven- munity has been participating in Live Well, San tion program with Sharp Memorial Hospital to Diego! For example, the County of San Diego empower chronically ill patients to take active teamed up with the San Diego Business Journal roles in their own wellness after discharge. In the to support the promotion of employee wellness first 10 months, 138 patients have taken part in through their San Diego’s Healthiest Companies the program, and participation has resulted in a Award competition. In so doing, we have begun reduction of the 30-day readmission rate to 2.3 to highlight wellness efforts across the com- percent, as compared to the 12.6 percent read- munity, issue calls to action and provide positive mission rate for non-participants. examples for other companies to follow. In ad- It should be noted that our efforts to improve dition, the County has worked with the business the health of the region didn’t start with Live community to create and support breastfeeding Well, San Diego! Rather, Live Well, San Diego! programs. When you think of programs that has truly been built upon the groundwork laid by can have short- and long-term benefits that are the local health and social service provider com- low-tech and low-cost, breastfeeding certainly munity over the past few decades. As a result springs to mind. We know that breastfeeding in of these long-standing efforts, we have begun the workplace helps avoid absenteeism on be- to see encouraging trends emerge. We are one half of parents and will help make for a healthier of the few regions in the nation to reduce heart child—who will hopefully grow up to become a disease and stroke from the first leading cause healthier worker in the future. Another example of death from chronic disease to the second is our efforts to support ICANATWORK.org, a leading cause. Furthermore, the University of free website where any San Diego organization California at Los Angeles recently completed an can join and create campaigns to promote em- independent evaluation of childhood obesity, ployee wellness. One major take-away from all finding that San Diego County reduced obese/ of these efforts has been that you can’t incentiv- overweight children by 3.7 percent—the largest ize businesses to promote employee wellness by reduction in Southern California.24 burdening them with more regulations; instead you have to demonstrate how embracing em- Despite these encouraging trends, there is still ployee wellness improves the bottom line for much work to be done. This journey ahead will both business and its surrounding community. require continuous innovation, commitment to ex- cellence, and engagement of not only those within Of course, we have to go beyond the business government, but our entire citizenship. Due to the community to achieve population-level health scale of what we are undertaking, it will take many improvements. To do so, we have created a more years—and perhaps even generations—to “SEA of Change”: Support, Encouragement and see the true impact of Live Well, San Diego! Accountability between members of the San Diego community as we pursue the goals of I hope I’ve illustrated that Live Well, San Diego! Live Well, San Diego!23 Through federal grants isn’t about a singular, one-size-fits-all solution, or (including Communities Putting Prevention government alone—it’s more about the important to Work and the Community Transformation role of local government as a convener of all Grants) and new collaborations, we are eliminat- sectors to create community convergence around ing silos and working side-by-side with other health and wellness. And San Diego County entities in the region to promote wellness. We is not alone in this quest for wellness—other are working with the Navy Southwest Region jurisdictions throughout our great nation are and Medical Center, for example, to increase making great strides on the wellness front. My collaboration and address health challenges that hope is that we can patch our collective efforts to face military families, such as tobacco use, obe- achieve sustainable results to win back our nation’s sity, and mental health awareness. In addition, health—that we can achieve “Live Well, America!” 24 Prevention in Action New York City Goes from “Want a Cigarette?” to “Yes, I mind if you smoke” By Elizabeth Kilgore, Director, Media and Education, Bureau of Tobacco Control, NYC Department of Health & Mental Hygiene I n 2002, New York City elected Mayor Michael Bloomberg. He, along with the Health Commissioner at the time, Dr. Disease, which affects those with a history of heavy smoking or chewing tobacco. As a result, Marie has had most of her fingers, a Thomas Frieden, made tobacco cessation leg and a foot amputated. and the prevention of tobacco-related ill- Through these ads, Marie has become a nesses and chronic conditions their number local celebrity — people recognize her and one priority for the health department. often tell her they quit smoking because To truly prevent tobacco-related illnesses of her. Marie shows that it’s never too late and conditions, we knew we had to help to quit. When we showed her ads, 30,000 large numbers of people and implement sci- New Yorkers called our quit line in 16 days. entifically-proven, population-based inter- In New York City, we have seen a great de- ventions. We developed a five-point plan: cline in tobacco prevalence. In 2002, preva- 1. Price increases: studies have shown lence was at 21.5 percent, and it is now 14 taxes to be the most effective way of re- percent. And, youth smoking is lower than ducing smoking prevalence; ever, at about 7 percent. 2. Legislation and policies that promote As we’ve seen these successes, other cities smoke free air: New York City was one and communities have asked for our help of the first in the country to pass a com- and best practices. We sometimes find that prehensive smoke-free law that included all communities are reluctant to tell the hard workplaces including bars and restaurants; truth of smoking related illness and would prefer more aspirational, feel good messages. 3. Cessation: make cessation medications and services as available as possible to every I suggest jurisdictions really investigate the New Yorker who wants them; data on the effectiveness in New York City and Australia on the ads — they work. 4. Mass public education campaigns: we learned a lot Many of New York City’s ads have been shown all over the from what California, Massachusetts and Australia had done world; when ads are effective from New York City to the with media, most notably graphic depictions of the health con- Ukraine to India, there’s something there. People don’t want sequences of smoking in the hopes of encouraging people to to get sick, suffer, die and devastate their families; and com- prevent developing these conditions; and munities want to prevent illnesses. 5. Research and evaluation: Both Dr. Frieden and our cur- While you might get calls from the community complaining rent commissioner, Dr. Thomas Farley, want to understand when airing these campaigns, the reality is that smoking causes the impact of our work and ensure the interventions we ugly terrible things; these ads tell the truth. We’ve seen it in implemented curb tobacco prevalence and prevent tobacco- New York City with stark ads: people will quit smoking and related illnesses. you will save lives. Perhaps, the most unique aspect of our plan was the public That said, there are no quick fixes and cessation isn’t the education campaign. We found that developing and dissemi- result of one intervention. While one intervention can make nating educational campaigns that depict the harsh realities of a huge difference, it’s all the pieces of our tobacco control the consequences of smoking (both on the smoker and those 5-point-plan in combination. who live with and care for the smoker) helps people take the initial step toward quitting. With all the pieces, we have seen a dynamic culture shift in New York City. Our community went from people asking one In my personal life, friends and new acquaintances routinely another, “want a cigarette?” to “mind if I smoke?” with most ask about the campaign featuring Marie. Marie has Buerger’s people saying, “yes, I do indeed mind.” 25 Prevention in Action Pitt County: Celebrating our Community and our Community’s Wellness By James Rhodes, Planning Director, Pitt County, North Carolina P eople talk about prevention initiatives such as shared use policies and farmers markets as if they are new and maybe they are for them. However, that’s not the case for Pitt County, as we have been, apparently, on the forefront of these initiatives for some time. In 1978, the county created a shared use policy to open school sites for recreational and com- munity activities. It quickly became how we were brought up. I coach basketball and can easily secure a gym for practice. As a county citizen, I can reserve any facility as long as it isn’t being used at that time for a school function. This goes way beyond gyms to include any fields, trails and most other grounds. which is one and one quarter acres, we had a In fact, most of our schools have trail systems that waiting list for folks that wanted their own plot connect through the neighborhoods, which can of land. There was huge excitement and that has be used for hiking, biking and running. continued to this day. A resident who moved here from North Dakota was one of the first Quite simply, our community tries to get people in line for the community garden. She everything they can out of the land and it really never expected the level of community camara- does help people get physically active. derie among the gardeners. She gets good exer- With the shared use policies, it’s also been far cise and grows healthy foods to serve her family. easier to make additional investments in school The gardeners come down to walk on the trail, facilities. Private individuals have paired with meet a relative or neighbor — it has created a public funding to supplement what schools nice family and intergenerational atmosphere. have — anything from infield dirt for a baseball In addition, our senior center residents use the diamond to additional resources for trails. The garden to help educate elementary school kids land serves all capacities — the school invests in about gardening and kindergarten classes have les- it and the community invests in it. sons there. In fact, they had their own jambalaya More recently, we’ve extended the nature of cooking project at the height of the growing sea- shared use to parks. We even developed a centrally son. The kids really enjoyed themselves, but also located district park that serves as a hub for the were introduced to healthy vegetables and foods community — it is near schools, our greenhouse that are grown in their community. facilities, the animal shelter, our farmer’s market, We know we aren’t perfect — we constantly the recycling center and the senior’s center. need to work to help people stay healthy and We have been able to create connectivity be- happy, and, to that end, we’ve expanding our tween all activities — so instead of just dropping reach to corner stores in food deserts to market of recycling, residents also visit the market or fruits and vegetables prominently. take a hike around the connecting trails. For us, it all started with the shared use policy In fact, the farmer’s market is right by one of the in 1978. Since then, the community has bought trails that is over a mile long and runs around into a healthy lifestyle and we’ve been able to do the park. It is also adjacent to the community more and more to help more and more people garden. When we planned to open the garden, stay fit, active and productive. 26 Prevention in Action San Antonio: A Community Making Healthy Choices By Maggie Thompson, Health Program Manager, San Antonio Metropolitan Health District S an Antonio is a great community. We have a mayor who cares deeply about health and a community that, when given the opportunity, will strive to be healthier. In addition, San Antonio became the first city in Texas to have a Bike Share program thanks to collaboration between Metro Health and the Office of Environmental Policy. Now, Austin and Houston are modeling similar initiatives after ours. We established In the last two years, the San Antonio Met- a Ride-to-Own bicycle program which has ropolitan Health District (Metro Health) flourished in underserved communities and through the Communities Putting Preven- provided over 1200 bicycles to residents. tion to Work grant has created around 30 initiatives that help make the healthy By working with the Mayor’s office and choice the easier choice. other city departments, we’ve made health a community movement. Mayor We increased access to healthy foods and Julián Castro established a Mayor’s Fitness opportunities for physical activity, and Council and has heavily promoted these we’ve worked on changing the built en- initiatives. This gives our programs more vironment so that parks and community community support and awareness. and residential areas are supportive of a healthy lifestyle. We recently passed a The community spirit is evident during Sí- Complete Streets ordinance that requires clovía, a free event that temporarily makes new city-sponsored streets to provide selected San Antonio streets available to support for bikes and pedestrians. residents for recreational and sports activi- ties so participants can bike, run, skate- We have also partnered with city board, etc. without worrying about cars. departments, such as the Library, the Because our first Síclovía was so popular, Planning Department, Public Works, the we were approached by Fiesta San Anto- Office of Environmental Policy, and the nio to incorporate a health focus. Fiesta is Parks Department to improve health. the city’s week-long celebration each year Through the Parks Department, “Fitness in with festivals, parades and numerous ac- the Park” provides free classes to city residents, including Yoga, tivities. We are launching a “Fit Fiesta” to allow people access Zumba, boot camps and other exercise classes. In addition, we to healthy activities and foods. While this is a small step, it is placed outdoor fitness stations in 25 parks. When the National an encouraging move toward making one of our biggest com- Recreation and Parks Association came to view our program, San munity gatherings healthier. Síclovía will be a pre-Fiesta event Antonians went up and thanked them, thinking they had provided to kick off a Fit Fiesta. the resources – our community was that appreciative of the fit- We’ve found that if we provide the community with ways to ness stations. Since we installed the outdoor fitness stations, park be healthy and exercise, they will enthusiastically use these use has gone up. resources. While we’ve had great accomplishments, we need With the local Independent School Districts, we’ve put 108 salad to keep up the momentum. bars in schools, which reach 100,000 students. We’ve provided This is a start, it is incredibly important to change the attitude physical activity equipment to 365 schools to ensure 350,000 of residents to give them opportunities. If they have few op- students are moving, active, and understand the importance of tions, they are more likely to stay inside – it’s as simple as that. healthy behaviors. We have also placed health assessment stations, outdoor fitness equipment and walking trails on the grounds of By focusing on preventive initiatives, we provide wonderful local libraries. Families can enjoy both reading and physical activity. opportunities to improve the health of the community. 27 Prevention in Action Ensuring Healthy Habit Development in Child Care By Ashley Obiaka, MPH, Board of Director, Jefferson County Department of Health T he state of Alabama ranks second in obesity compared to the other 50 states in the na- tion, with an adult obesity prevalence rate of 32.3 ongoing support and education, while assisting with compliance. Other requirements involve employee background checks, safe and hygienic percent. Obesity is a significant health issue be- facilities and practices, clean and safe physical cause it contributes to high health care costs and structures, clean and well-maintained objects, as chronic disease development. Prevention should well as food service rule adherence. United Way begin during early childhood since obese and of Central Alabama, Alabama Breast Feeding overweight children are likely to continue this un- Coalition, Healthy Child Care, Child Care Re- healthy weight gain trend into adulthood. There- sources, Success By 6 and Alabama Department fore, improving children’s opportunities to develop of Human Resources contributed to the process healthy behaviors during early childhood becomes and Mobile’s regulations were used as a guide. an important strategy towards mitigating obesity. In Jefferson County, Alabama, child advocacy or- ganizations and businesses and government agen- cies who understood the importance of facilitating healthy habit development in children, took action. Regulations In 2011, the Jefferson County Department of Health developed and adopted child care health and safety regulations to ensure general well- ness for children in Jefferson County. Alabama Department of Human Resources (DHR) pro- vides minimum standards for child care centers; however, they are applicable only to licensed centers. In 2007, the Mobile County Depart- Assessment, Training and Incentives ment of Health adopted safety standards for Success By 6 used the Nutrition and Physical children; however, they do not include nutrition Activity Self Assessment for Child Care (NAP and physical activity requirements. JCDH capi- SACC) to assess child care centers and develop talized on the strengths of both DHR’s minimum nutrition and physical activity improvement plans. standards and Mobile’s safety regulations by Childcare Resources provided child care center developing and adopting regulations that include staff with tailored physical activity and nutrition child health requirements and apply to all child training, which provided them with information care centers regardless of license status. required to make healthy food and physical activ- ity time available to children. Furthermore, child For example, Jefferson County’s new regulations care centers that exhibited leadership and high require that children be provided with opportu- need were competitively awarded playground nities to engage in physical activity with develop- equipment. Playgrounds were built and installed mentally appropriate equipment; daily physical with community and local business volunteers. activity must be included on child care schedules and prominently posted; and screen time must Conclusion be limited. Meals and snacks served to children Jefferson County took a comprehensive ap- must comply with USDA guidelines; water proach to ensure healthy habit development in should be made available during meal times; and children frequenting over 360 child care centers. at least half the grains served each week must As a result, the course of a child’s day will be be whole grains. Child care centers are also positively impacted by required health practices, required to receive child care training that was safe playground facilities, child care training and developed to provide child care centers with improvement plans. 28 Prevention in Action Tobacco Advisory Signs, Promising Practice Implementation T he Jefferson County Department of Health (JCDH) launched an initiative to post tobacco advisory signs at point of purchase through incentivizing voluntary signage place- ment. With the goal of increasing awareness, reducing smoking rates and youth initiation, six 11”x17” signs were developed depicting risks associated with tobacco use such as cancer, im- potence and respiratory problems in children. In addition, each sign promotes Alabama’s Quitline number as a resource for smokers to use and to increase cessation attempts. Placing sig- nage where tobacco products are purchased is the ideal place to influence the minds of tobacco users. The tobacco industry has strongly advertised in the retail environment; convenience stores and small grocery stores are among venues heavily targeted. Leading the initiative, the Tobacco Retail Warnings Specialist focused on convenience In order for a successful environmental systems change, this stores. As the primary outlet in underserved neighborhoods, initiative proposed to use the exiting food inspection platform they are an ideal location to convey healthful information in an as a vehicle for sustainability. Although JCDH does not have environment where its reach may otherwise be limited. jurisdiction over all tobacco retail establishments, 80 percent The design of the six tobacco advisory signs was influenced by of them also carry food permit. With such a high percentage focus groups’ feedback, the FDA proposed images for cigarette of retailers holding JCDH issued food permits and thus under- packets, and evidence based research. A Behavioral Risk Fac- going routine health inspections by JCDH inspectors, the food tor Surveillance System (BRFSS) report released in December permits provides the ideal avenue through which those retail- 2011 revealed that 78 percent of people surveyed in Jeffer- ers could be incentivized to voluntarily support the tobacco son County were in favor of having tobacco advisory signage advisory signage initiative. In October 2011, the Jefferson posted in their neighborhood convenience store, pharmacy, or County Board of Health unanimously voted to adopt a policy grocery store. Furthermore, studies have shown that smokers to incentivize convenience stores and other venues selling in countries with posted tobacco advisory signage were much tobacco products (with a JCDH issued food permit) to volun- more likely to understand the adverse health effects associated tarily post tobacco advisory signage. The incentive includes with smoking and reported they actually believe the health awarding two points to the participating venue’s overall health hazards portrayed by the signage to be true. rating given no critical violations are assessed during routine health inspections. The two incentive points are awarded The Tobacco Retail Warnings Specialist initially canvassed 61 con- if signage is posted at the point of purchase or in other con- venience stores randomly chosen within Jefferson County. Out spicuous areas. Because the compliance is voluntary, point of the 61 convenience stores, finalized signs were placed in 50 of of purchase placement was strongly recommended but not them. Through one on one visits, each retail store’s owner or key mandated. Monitoring of initiative through continues site decision maker was informed about the initiative, its importance visits and quarterly reports will provide compliance rates to and incentive to support it. A toolkit was presented highlighting further advance police change. The Tobacco Retail Warnings smoking related health statistics, research, and other information Specialist provided technical assistance to the JCDH health to get buy-in from the owner as a long term supporter of posting inspectors. This technical assistance educated the inspectors the signage. All participating owners were asked to sign a pledge on how to assess proper placement of signage with warrants of support stating their willingness to voluntarily comply. After a awarding the incentive points and address any fundamental three month follow up to the 50 original convenience store own- questions the retailers may have. ers that agreed to voluntarily post signage, there has been a 94 percent retention rate at the time of follow-up visits. 29 Prevention in Action Cutting Health Care Costs Through Prevention: Manatee County, Florida By Kim Stroud, Benefits Manager, Manatee County M anatee County has 3,200 employees, or, as we think of it, 6,900 lives, including families. In early 2000, our health care costs were skyrocketing, mostly “When my wife and I were first required to qualify for the Good, Better, Best medical insurance, I could not under- stand why we had to do the age based testing, but due to due to chronic conditions. At the time, the county was cover- ing the entire share of the employee premium, but this became personal experiences, today I do and I am so GRATEFUL. untenable. We had a decision to make: how do we continue to fund the increase in health care and do we continue to absorb –Manatee Employee those costs ourselves or do we shift them to the employee through premium increases or require more employee out of pocket expenses through the benefit design? That said, we knew we had to continue to provide employees with We knew both choices had their minuses, so we did neither. the resources to help them make the healthy choices. So, we fo- cused on on-site integrated person-to-person coaching and creating Starting in 2006, we created the YourChoice Health Plan, access to wellness resources, such as access to fitness equipment which ties preventive health care and evidenced-based prac- tices with employee plan level eligibility. The plan is a tradi- For instance, we use an addiction model to work with our em- tional PPO, but within it, we have four levels. The highest level, ployees who use tobacco. After implementing the plan, only 13 or the Ultimate plan, requires only a copay for office visits and percent of our employees use tobacco — the average in Florida is hospitalization is paid at 100 percent. 20 percent. We saw dramatic decreases in known tobacco users when we implemented the plan. Often, tobacco-users are looking Essentially the member pays only approximately six percent of for ways to quit and they credit the plan with giving them a rea- a claim. However, we didn’t allow employees to simply get into son. And we know they quit because it is verified by lab tests. the plan. To qualify, employees had to take a comprehensive lab draw, wellness exam, complete a health risk assessment (HRA) and be prescreened for diabetes, nicotine exposure and other health indicators. “I am currently taking the Pilates class on Tuesday If the employee had diabetes, to enter the plan, he/she had to follow the American Association of Diabetes recommendations evening and really enjoying it. I’m looking forward to for treating the condition. If the employee was a tobacco user, continuing with something after this 12 week session. they had to complete a four course education program. I love the fitness center. Myself and my exercise buddy After implementing the plan, our former benefits manager was in the elevator. An employee got on the elevator with him and had been walking the parking garage (YUCK!!!!) and got tears in her eyes. The employee said, “I can’t thank you had been going over to the old gym which sometimes had enough. By you forcing me to get my diabetes test, I now feel WAAAYYYYY too much man stuff going on. Having the better than I have in 20 years. I am more productive and am better at work because, previously, my blood sugar was never fitness center is a real blessing. I’m also so happy to finally under control.” She was ecstatic to be healthy and productive be able to be have classes downtown. I live out east and — so much so that she grabbed and hugged him. there was nothing for me out that way in the evening so The plan worked: 93 percent of our employees did everything being able to change here and just run downstairs is great.” asked of them, which is remarkable. Quite simply, it is unheard of for 93 percent of a population to undertake a health risk as- –Manatee Employee sessment. (The other seven percent were moved to the alter- native higher cost option plan.) 30 Defining Success While we know our methods are improving lives, it can be hard to quantify success, i.e., how do you measure a claim that never occurred. For our plan to be successful, our outcomes needed to show that our plan drives employees to healthier habits and preventive care. We needed to catch and possibly prevent chronic conditions from ever developing. We can show success through several avenues. For one, we have seen an annual reduction in out of range blood lipids (choles- terol), which indicates we are catching things early and people are getting interventions when they need it. We have a diabetic educator on staff who also ensures that all members with diabe- tes obtain annual routine eye and foot exams along with regular HbA1C checks. Before we implemented this practice we had $500,000 in diabetes-related hospital fees. Since we created our plan, we spend $70,000 on diabetes-related hospital fees. In addition, when comparing 2010 to 2011, we achieved a negative trend: we spent approximately 4 percent less (over $2 million) in 2011 than in 2010. We achieved these results by a 9.5 percent re- “I wanted to comment on the Diabetic Program. My duction in chronic care spending, a 22 percent reduction in inpatient husband was recently diagnosed as diabetic. About hospitalization and an 11 percent reduction in emergency room costs. These outcomes clearly show that the efforts back in 2006 of two months ago we both met with our counselor and directing employees to preventative care and creating our onsite in- she set my husband up with a diet and exercise pro- tegrated health management and wellness team that guides employ- gram and provided the meter to test his blood daily. ees to better health is showing a significant return on investment. Some people know what to do to get healthy and some people To date, my husband has lost 20 pounds that he don’t. Our plan helps those who know how to get healthy and those needed to lose and has a goal to lose another 20. Ad- that don’t — we see the plan as a nice blend of the carrot and the ditionally, when he went to see his counselor yesterday stick. We provide rewards but also requirements and it works. to download the information from his meter, his sugar To assist employees in improving their health, we have an on- site, integrated health management and wellness team that had been within the normal range every day for the works together to deal with the whole person. On-site we last 6 weeks. These fantastic results are based on the have Registered Nurses, Behavioral Health Specialists, Regis- suggestions for exercise, diet and ‘carb counting’ that tered Dieticians, Clinical Pharmacists and Exercise Physiologists. Before coming to Manatee, I was a therapist in the community. our counselor helped with.” If I had someone who was depressed and had diabetes, I didn’t –Manatee Employee have a lot of options to get that person connected with re- sources to help with the diabetes. At Manatee, if we have a dia- betic employee who is depressed, our dietician can connect him with the therapist who is on-site and part of the health manage- ment team — we can treat the physical and emotional needs at the same time and prevent further complications. 31 Prevention in Action Go the Greenway: Mecklenburg County, North Carolina T here is a clear public need and desire for greenways and trail development in Mecklenburg County. In the fall 2007 and early 2008, a series of public meetings were held to provide public Toby Creek Greenway and West Branch Rocky River Green- way will add to the Carolina Thread Trail greenway network which will eventually extend over 500 miles into 15 counties input into the Park and Recreation planning process. Greenways and to 2 million people. and trails were a major topic of discussion at these meetings. Ad- “Both West Branch Rocky River Greenway and Toby Creek ditionally, a community survey conducted by ETC Leisure Vision Greenway add important sections to our overall greenway sys- found greenways and trail development was an important and tem,” said Park and Recreation Greenway Planner Gwen Cook. unmet need for the majority of Mecklenburg County residents. “Without the funding, neither project would be possible.” The results of the 2008 Mecklenburg County Park and Recre- The impact of the stimulus money has enabled Park and Rec- ation Master Plan clearly reveal the public’s appreciation for reation’s greenway division to continue carrying out its mis- natural areas and their desire for a trail system. sion of providing natural transportation and fitness areas that Survey results indicate County residents understand and sup- help to improve water quality, reduce the impacts of flooding, port the role of greenways as both corridors for environmental and provide wildlife habitat. protection and potential trail development. Ninety-three per- Improving the public’s health cent of all residents felt the role of greenways as a connected A region’s trail network will contribute to the overall health of network of walking, biking and nature trails was very important residents by offering people attractive, safe, accessible places Connecting people and places to bike, walk, hike, jog, skate, and possibly places to enjoy Mecklenburg County currently has 37 miles of developed and 150 water-based trails. In short, the trail network will create better miles of undeveloped greenways. The most notable being the Little opportunities for active lifestyles. The design of communities— Sugar Creek Greenway which stretches through the heart of Char- including towns, subdivisions, transportation systems, parks, lotte. When complete, the greenway will feature over 19 miles of trails and other public recreational facilities—affects people’s trails and land connectors, from Toby Creek Greenway on North ability to reach the recommended 30 minutes each day of Tryon Street to Cordelia Park just north of uptown. The greenway moderately intense physical activity (60 minutes for youth). will continue through the urban section and on to the South Caro- According to the Centers for Disease Control and Prevention lina state line, conveniently linking Central Piedmont Community (CDC), “Physical inactivity causes numerous physical and men- College, Carolina Healthcare System and the Park Road and Caro- tal health problems, is responsible for an estimated 200,000 lina Place shopping areas among many other destinations.  deaths per year, and contributes to the obesity epidemic.” Federal Support In identifying a solution, the CDC determined that by creat- In 2009, Park and Recreation received $2.35 million in federal ing and improving places in our communities to be physically stimulus funding for the construction of Toby Creek Green- active, there could be a 25 percent increase in the percentage way in the University City area and West Branch Rocky River of people who exercise at least three times a week. This is Greenway in Davidson. significant considering that for people who are inactive, even The funding was provided by the American Recovery and small increases in physical activity can bring measurable health Reinvestment Act (ARRA) of 2009 and obtained through the benefits. Additionally, as people become more physically ac- Mecklenburg Union County Metropolitan Planning Organization tive outdoors, they make connections with their neighbors (MUMPO) through a competitive ranking process. Originally, that contribute to the health of their community. the two projects were supposed to receive funding with 2004 Park and Recreation bonds that the County never issued due to The above was provided by Mecklenburg County Park and Recreation. the economic downturn. 32 Recommendations A merica’s future economic well-being is inextricably tied to our health. High rates of preventable diseases are one of the biggest drivers of health care costs in the country. And, right now, Americans are not as healthy and productive as they could or should be to compete in the global economy. 4 Section In tough economic times, it is more important TFAH recommends that: than ever to invest in the health of Americans. 1. Core funding for public health — at the fed- Improving the health of Americans is essential eral, state and local levels — be increased; for reducing health care costs and increasing our productivity — to help get the economy 2. unding be considered strategically — so funds F back on track for the long term. are used efficiently to maximize effectiveness in lowering disease rates and improving health; The nation’s public health system is respon- sible for keeping Americans healthy and safe. 3. The Prevention Fund be targeted to effec- Public health is devoted to preventing disease tively and efficiently reduce rates of disease and injury. If we successfully kept Americans by focusing on efforts that help to modernize healthier, we could significantly improve health, our approach to public health — from invest- drive down trips to the doctor’s office, and re- ing more in locally-determined, evidence- duce health care costs. based prevention activities to strengthening the core capacity of health departments to In addition to shoring up the core ongoing operate in a reforming and technologically funds for public health, we need to ensure the advanced health care system; and new Prevention Fund is used to build upon and expand existing efforts, not supplant. If we 4. Accountability must be a cornerstone of pub- do not keep the foundation of support intact, lic health funding — the use of funds and the we will never advance in the fight to prevent outcomes achieved from the use of the funds diseases, curb the obesity epidemic, or reduce should be transparent and clearly communi- smoking rates. cated with the public. 33 Appendix A: Notes on Data and Methodology T he sources for the funds and indicators come from a variety of publicly avail- able sources. In some cases fiscal years for funding may vary depending on availability of data, and year of health indicators may vary slightly as well. Funding References CDC Funds for State and Local Health Depart- “Public health” is defined to broadly include all health ments, Universities, & Other Public and Private spending with the exception of Medicaid, CHIP, or Agencies FY 2011 data were all provided by the comparable health coverage programs for low-income U.S. Centers for Disease Control and Prevention’s residents. Federal funds, mental health funds, addic- Financial Management Office. The total (all cat- tion or substance abuse-related funds, WIC funds, ser- egories) was also provided by the CDC; it includes vices related to developmental disabilities or severely program areas not highlighted here. CDC Per Capita disabled persons, and state-sponsored pharmaceutical Total FY 2011 calculated by TFAH by dividing programs also were not included in order to make the CDC provided total by July 1, 2011 U.S. Census Bu- state-by-state comparison more accurate since many reau population estimates. CDC Per Capita Ranking states receive federal money for these particular pro- based on TFAH calculated per capita totals. grams. In a few cases, state budget documents did not allow these programs, or other similar human services, HRSA Health Professions, HIV/AIDS, Maternal to be disaggregated; these exceptions are noted. For & Child Health, and Primary Health Care FY 2011 most states, all state funding, regardless of general rev- funding data come from HRSA’s Geospatial Data Ware- enue or other state funds (e.g. dedicated revenue, fee house, State Profile Report (accessed February 2012.) revenue, etc.), was used. In some cases, only general The total HRSA dollar amount also came from this revenue funds were used in order to separate out fed- source. HRSA key program area totals, however, were eral funds; these exceptions are also noted. calculated by TFAH using Microsoft Excel. HRSA Per Capita Total FY 2011 calculated by TFAH by dividing Because each state allocates and reports its budget in HRSA Total dollars by July 1, 2011 U.S. Census Bu- a unique way, comparisons across states are difficult. reau population estimates. HRSA Per Capita Ranking This methodology may include programs that, in come based on TFAH calculated per capita totals. cases, the state may consider a public health function, but the methodology used was selected to maximize ASPR Hospital Preparedness Program FY 2011 the ability to be consistent across states. As a result, funding from U.S. Department of Health and Human Ser- there may be programs or items states may wish to be vices: Office of the Assistant Secretary for Preparedness considered “public health” that may not be included and Response Office of Preparedness and Emergency in order to maintain the comparative value of the data. Operations Division of National Healthcare Prepared- ness Programs. “FY11 Revised Hospital Preparedness Finally, to improve the comparability of the budget Program Funding Table.” (accessed November 1, 2011). data between FY 2009-2010 and FY 2010-2011 (or between biennium), TFAH adjusted the FY 2010- State Public Health Budget Methodology TFAH 2011 numbers for inflation (using a 0.9652 conver- conducted an analysis of state spending on public sion factor based on the U.S. Dept. of Labor Bureau health for the last budget cycle, fiscal year 2010-2011. of Labor Statistics; Consumer Price Index Inflation For those states that only report their budgets in bien- Calculator at http://www.bls.gov/cpi/).   nium cycles, the 2009-2011 period (or the 2010-2012 and 2010-2011 for Virginia and Wyoming respec- After compiling the results from this online review tively) was used, and the percent change was calculated of state budget documents, TFAH coordinated with from the last biennium, 2007-2009 (or 2008-2010 and the Association of State and Territorial Health Of- 2009-2010 for Virginia and Wyoming respectively). ficials (ASTHO) to confirm the findings with each state health official.  ASTHO sent out emails on Oc- This analysis was conducted from August to Octo- tober 26, 2011 and state health officials were asked ber of 2011 using publicly available budget docu- to confirm or correct the data with TFAH staff by ments through state government web sites. Based November 11, 2011.  ASTHO followed up via email on what was made publicly available, budget docu- with those state health officials who did not respond ments used included either executive budget docu- by the November 11, 2011 deadline.  In the end, 10 ment that listed actual expenditures, estimated states did not respond by November 18, 2011 when expenditures, or final appropriations; appropriations the report went to print.  These states were assumed bills enacted by the state’s legislature; or documents to be in accordance with the findings.  34 from legislative analysis offices. Population Facts U.S. Total Population estimates come from the Coverage Status by State for All People: 2010. (ac- U.S. Census Bureau 2011, National and State Popu- cessed November 1, 2011). lation Estimates, Resident Population Data, released Total Number of Uninsured, under18 estimates December 2011 (accessed January 3, 2012). come from the U.S. Census Bureau. Current Popu- Total Number of U.S. Uninsured, All Ages esti- lation Survey, Table HI05: Health Insurance Cover- mates come from the U.S. Census Bureau, Current age Status and Type of Coverage by State and Age Population Survey, Table HI06. Health Insurance for All People: 2010 (November 1, 2011). Adult Health Indicator References **Note: Some Behavioral Risk Factor Surveillance System (BRFSS) statistics use three years of combined data to “stabilize” yearly figures. TFAH contracted with Dr. Edward Okeke to carry out this data analysis. Adult Physical Inactivity Rate 2008-2010 3 Yr Av- responding “ever been told” they have diabetes. erage data come from the BRFSS Prevalence Data National Center for Chronic Disease Prevention & 2008-2010, percent responding “did not engage in Health Promotion, Centers for Disease Control and any physical activity”. National Center for Chronic Prevention. Available at BRFSS Data. Disease Prevention & Health Promotion, Centers Fruit and Vegetable Intake 2005-2009 3 Yr Aver- for Disease Control and Prevention. Available at age data come from the BRFSS Prevalence Data BRFSS Data. 2005-2009, percent who consume the recom- AIDS Cumulative Cases Aged 13 and Older mended at least 5 servings of fruit and vegeta- 2009 Yr End data come from the U.S. Centers for bles daily.  Available at BRFSS Data. Disease Control and Prevention, National Center Human West Nile Virus Cases 2011 data come for HIV, STD, and TB Prevention, Table 20, HIV/ from the 2011 West Nile Virus Human Infections AIDS Surveillance Report: Cases of HIV Infection in the United States (accessed November 2, 2011). and AIDS in the United States, 2009 Cumulative (accessed November 2, 2011). Hypertension 2005-2009 3 Yr Average data come from the BRFSS Prevalence Data 2005-2009, per- Alzheimer’s Estimated Cases among 65+ (2025) cent responding “ever been told” they have high data come from the Alzheimer’s Association report blood pressure. Hypertension data is collected Alzheimer’s Disease Facts and Figures 2011 (No- only on odd-numbered years. To stabilize the data, vember 1, 2011). researchers used combined data from 2005, 2007 Asthma 2010 data come from the BRFSS Prevalence and 2009. National Center for Chronic Disease Pre- Data 2010, percent responding “ever been told” they vention & Health Promotion, Centers for Disease have asthma. National Center for Chronic Disease Control and Prevention. Available at BRFSS Data. Prevention & Health Promotion, Centers for Disease Obesity 2008-2010 3 Yr Average data were calcu- Control and Prevention.  Available at BRFSS Data. lated by contractors using self-reported height Breast Feeding Report Card 2008 data come and weight measure from the BRFSS Prevalence from “Breastfeeding Report Card, United States: Data 2008-2010. National Center for Chronic Outcome Indicators.” CDC National Immunization Disease Prevention & Health Promotion, Cen- Survey, Provisional Data, 2008 births.  (accessed ters for Disease Control and Prevention. Avail- November 2, 2011). able at BRFSS Data. Obesity was defined as having a BMI greater than or equal to 30. Cancer Estimated New Cases 2011 data come from the American Cancer Society’s Cancer Facts Pneumococcal Vaccination Rates 65 and Over and Figures 2011 (accessed November 2, 2011). 2010 data come from the BRFSS Prevalence Data 2010.  National Center for Chronic Disease Pre- Chlamydia Rates per 100,000 Population (2010) vention & Health Promotion, Centers for Disease data come from the Division of STD Prevention, Na- Control and Prevention.  Available at BRFSS Data. tional Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, U.S. Centers for Disease Control Seasonal Flu Vaccination Rates 65 and Over 2010 and Prevention Sexually Transmitted Disease Sur- data come from the BRFSS Prevalence Data 2010.  veillance, 2010 (accessed November 29, 2011). National Center for Chronic Disease Prevention & Health Promotion, Centers for Disease Control Diabetes 2008-2010 3 Yr Average data come from and Prevention.  Available at BRFSS Data. the BRFSS Prevalence Data 2008-2010, percent 35 Syphilis Rates per 100,000 Population (2010) percent responding they are current smokers. data come from the Division of STD Prevention, National Center for Chronic Disease Prevention National Center for HIV/AIDS, Viral Hepatitis, & Health Promotion, Centers for Disease Con- STD, and TB Prevention, U.S. Centers for Dis- trol and Prevention. Available at BRFSS Data. ease Control and Prevention Sexually Trans- Tuberculosis (TB) Number of Cases 2010 data mitted Disease Surveillance, 2010 (accessed come from “Reported Tuberculosis in the United November 19, 2011). States, 2010,” U.S. Centers for Disease Control Tobacco Use - Current Smokers 2010 data and Prevention (accessed November 2, 2011). come from the BRFSS Prevalence Data 2010, Child and Adolescent Health Facts AIDS Cumulative Cases Children Under 13 Infant Mortality per 1,000 Live Births 2008 data 2009 data come from the U.S. Centers for Dis- come from the National Center for Health Sta- ease Control and Prevention, National Center tistics, National Vital Statistics Report, Deaths: for HIV, STD, and TB Prevention, Table 20, Final Data for 2008 (accessed January 3, 2012). HIV/AIDS Surveillance Report: Cases of HIV Low Birthweight Babies 2009 data come from Infection and AIDS in the United States, 2009 the National Center for Health Statistics, Na- Cumulative (accessed November 2, 2011). tional Vital Statistics Report, Births: Final Data Asthma 2009 High School Students data come for 2009, State-specific Detailed Tables for 2009, from the Youth Risk Behavior Surveillance System, Table I-9 (accessed November 3, 2011). Comprehensive Results 2009, percent respond- Obese High School Students 2009 data come ing “ever been told” they have asthma. National from the Youth Risk Behavior Surveillance Sys- Center for Chronic Disease Prevention & Health tem, Comprehensive Results 2009. National Promotion, Centers for Disease Control and Pre- Center for Chronic Disease Prevention & vention. Available at: http://www.cdc.gov/mmwr/ Health Promotion, Centers for Disease Control pdf/ss/ss5905.pdf (accessed October 19, 2010). and Prevention. Available at http://www.cdc. Fruit and Vegetable Behavioral Indicator Stu- gov/HealthyYouth/yrbs/index.htm. dents data come from the Youth Risk Behavior Obese 10 to 17 Year Olds 2007 data come from Surveillance System, Comprehensive Results the National Survey of Children’s Health, 2007. 2009, percent responding “ate fruits or vegeta- Child and Adolescent Health Measurement bles five or more times/day” in the past seven Initiative. 2007 National Survey of Children’s days. National Center for Chronic Disease Health, Data Resource Center for Child and Prevention & Health Promotion, Centers for Adolescent Health website.  Available at http:// Disease Control and Prevention. Available at: www.nschdata.org/Content/Default.aspx (ac- http://www.cdc.gov/mmwr/pdf/ss/ss5905.pdf cessed July 6, 2009). (accessed October 19, 2010). Pre-Term Births as Percent of Live Births 2009 Immunization Gap: Children Aged 19 to 35 data the National Center for Health Statistics, Months without All Immunizations 2010 data National Vital Statistics Report, Births: Final Data come from Estimated Vaccination Coverage for 2009, Table I-8 (accessed November 3, 2011). with Individual Vaccines and Selected Vaccina- tion Series Among Children 19-35 Months of Tobacco: Current Smokers High School Students Age by State and Local Area U.S., National Im- 2009 data come from the Youth Risk Behavior Sur- munization Survey, 2010 (accessed November 3, veillance System, Comprehensive Results 2009, 2011). TFAH used the data for the 4:3:1:3:3:1:4 percent of “students who smoked cigarettes on series which is the CDC-recommended series for one or more of the past 30 days.” National Center children aged 19--35 months. The 4:3:1:3:3:1:4 for Chronic Disease Prevention & Health Promo- series is used to evaluate progress toward one of tion, Centers for Disease Control and Prevention. the Healthy People 2020 objectives, which aims Available at http://www.cdc.gov/mmwr/pdf/ss/ to achieve greater than 80% coverage with the ss5905.pdf (accessed October 19, 2010). series among children ages 19--35 months. 36 Other Public Health Indicators Health Professions Shortage Areas: Primary Projected Supply vs. Demand for RNs (2010) Care, Mental Health, Dental Care FY 2011 data comes from the National Center for Health data come from HRSA’s Geospatial Data Ware- Workforce Analysis in the Bureau of Health Pro- house, State Profile Report (accessed October fessions, Health Resources and Services Adminis- 28, 2011). tration paper “What Is Behind HRSA’s Projected Supply, Demand and Shortage of Registered Nurses?” Washington, D.C.: September 2004. Pandemic Preparedness Key Facts Ready or Not 2010 Emergency Preparedness In- modeling program developed by CDC, which dicators are from TFAH’s Ready or Not 2010, Pro- also considers the age and health risk factors of tecting the Public’s Health from Disease, Disasters, a state’s population. It should be noted that Flu and Bioterrorism, December 2010. Aid is limited in its ability to account for density issues, such as how close people live together in Potential # of Deaths During a Severe Pandemic cities versus rural areas. estimates in each state used the same assumptions of a 30 percent attack rate and a 2.5 percent case Potential Financial Loss during a Severe Pandemic, fatality rate. The rates were calculated using the % of GDP data comes from: Trust for America’s Flu Aid computer modeling program developed Health. Pandemic Flu and the Potential for U.S. by CDC, which also considers the age and health Economic Recession. Washington, D.C.: Trust risk factors of a state’s population.40 It should be for America’s Health, 2007. Available at: http:// noted that Flu Aid is limited in its ability to ac- healthyamericans.org/reports/flurecession/. count for density issues, such as how close people Potential Financial Loss during a Severe Pandemic, live together in cities versus rural areas. dollar amount data comes from: Trust for Ameri- Potential # of Episodes of Illness During a Se- ca’s Health. Pandemic Flu and the Potential for vere Pandemic estimates in each state used the U.S. Economic Recession. Washington, D.C.: Trust same assumptions of a 30 percent attack rate for America’s Health, 2007. Available at: http:// and a 2.5 percent case-fatality rate. The rates healthyamericans.org/reports/flurecession/. were calculated using the Flu Aid computer 37 Appendix B: State-by-State Adult Health Indicators Adult Health Indicators AIDS Percent Diabetes Adult Physical Chlamydia Cumulative Alzheimer’s Exclusive Cancer 2008-2010 2011 Census % Uninsured, Inactivity Rate Asthma Rates per Cases Aged Estimated Breastfeeding Estimated 3 Yr. Ave. State Population All Ages 2008-2010 3 Yr Prevalence 100,000 13 and Older Cases among at 6 Months- New Cases Percentage Estimates (2010) Average (95% 2010 Population – 2009 Yr 65+ (2025) -from Births - 2011 (95% Conf Conf Interval) (2010) End 2008^ Interval) Alabama 4,802,740 15.4% 30.5% (+/- 1.0) 9,974 110,000 11.8% 5.9% 25,530 574.3 12.2% (+/- 0.6) Alaska 722,718 18.0% 22.8% (+/- 1.6) 735 7,700 14.4% 17.1% 3,090 861.7 5.9% (+/- 0.8) Arizona 6,482,505 19.1% 21.4% (+/- 1.1) 12,293 130,000 14.8% 12.3% 31,550 407.2 9.2% (+/- 0.7) Arkansas 2,937,979 18.7% 29.7% (+/- 1.1) 4,524 76,000 13.6% 13.7% 16,070 533.8 9.8% (+/- 0.6) California 37,691,912 19.4% 21.9% (+/- 0.6) 160,998 660,000 12.6% 25.7% 163,480 407.0 8.7% (+/- 0.4) Colorado 5,116,796 13.0% 18.3% (+/- 0.6) 9,952 110,000 14.7% 24.0% 22,390 387.0 5.9% (+/- 0.3) Connecticut 3,580,709 11.0% 21.6% (+/- 0.8) 16,282 76,000 15.3% 16.2% 21,440 359.5 6.9% (+/- 0.5) Delaware 907,135 11.3% 23.3% (+/- 1.1) 4,181 16,000 15.1% 11.4% 5,130 504.3 8.4% (+/- 0.6) D.C. 617,996 12.5% 20.7% (+/- 0.5) 20,660 10,000 15.5% 17.1% 2,830 932.0 8.8% (+/- 0.6) Florida 19,057,542 20.8% 24.5% (+/- 0.8) 120,701 590,000 13.8% 12.9% 113,400 403.2 9.9% (+/- 0.5) Georgia 9,815,210 19.4% 24.1% (+/- 1.0) 39,207 160,000 11.5% 10.1% 44,580 459.3 9.7% (+/- 0.6) Hawaii 1,374,810 7.7% 19.5% (+/- 0.8) 3,235 34,000 17.6% 20.8% 6,710 464.4 8.3% (+/- 0.5) Idaho 1,584,985 19.2% 20.7% (+/- 0.8) 707 38,000 13.6% 22.1% 7,520 272.2 7.7% (+/- 0.5) Illinois 12,869,257 14.8% 25.8% (+/- 1.0) 38,886 240,000 13.6% 14.3% 65,610 469.9 8.4% (+/- 0.5) Indiana 6,516,922 13.4% 27.1% (+/- 0.9) 9,635 130,000 14.2% 11.4% 34,050 355.4 9.6% (+/- 0.5) Iowa 3,062,309 12.3% 24.7% (+/- 0.9) 2,029 77,000 11.6% 17.0% 17,500 350.5 7.4% (+/- 0.4) Kansas 2,871,238 12.7% 24.2% (+/- 0.6) 3,284 62,000 13.2% 10.6% 14,070 340.6 8.4% (+/- 0.4) Kentucky 4,369,356 14.9% 29.8% (+/- 0.9) 5,552 97,000 14.9% 9.8% 25,010 379.6 10.5% (+/- 0.5) Louisiana 4,574,836 20.0% 29.5% (+/- 0.8) 20,521 100,000 11.6% 7.8% 22,780 648.9 10.7% (+/- 0.5) Maine 1,328,188 9.4% 22.2% (+/- 0.4) 1,301 28,000 15.7% 18.5% 8,820 196.2 8.4% (+/- 0.4) Maryland 5,828,289 13.1% 23.6% (+/- 0.8) 35,981 100,000 12.4% 13.1% 28,890 459.6 9.1% (+/- 0.5) Massachusetts 6,587,536 5.6% 21.2% (+/- 0.6) 21,787 140,000 15.3% 14.1% 37,470 319.7 7.5% (+/- 0.3) Michigan 9,876,187 13.0% 24.1% (+/- 0.7) 17,126 190,000 15.8% 16.3% 57,010 496.3 9.5% (+/- 0.4) Minnesota 5,344,861 9.8% 17.6% (+/- 0.9) 5,707 110,000 10.9% 15.0% 27,600 290.4 6.3% (+/- 0.4) Mississippi 2,978,512 21.1% 32.6% (+/- 0.9) 7,905 65,000 11.6% 5.7% 14,990 725.5 11.8% (+/- 0.5) Missouri 6,010,688 14.0% 27.2% (+/- 1.1) 13,042 130,000 14.2% 12.0% 32,740 435.1 8.8% (+/- 0.6) Montana 998,199 18.1% 22.3% (+/- 0.9) 485 29,000 12.9% 23.0% 5,690 316.1 6.8% (+/- 0.4) Nebraska 1,842,641 13.3% 24.5% (+/- 0.8) 1,743 44,000 12.2% 13.4% 9,430 284.6 7.6% (+/- 0.4) Nevada 2,723,322 21.3% 25.0% (+/- 1.3) 6,834 42,000 14.5% 11.5% 12,800 365.7 8.3% (+/- 0.8) New Hampshire 1,318,194 10.3% 20.9% (+/- 0.8) 1,248 26,000 15.0% 19.6% 8,210 185.9 7.4% (+/- 0.4) New Jersey 8,821,155 15.4% 26.6% (+/- 0.7) 54,483 170,000 13.3% 10.3% 49,080 300.2 8.8% (+/- 0.4) New Mexico 2,082,224 21.6% 22.6% (+/- 0.9) 3,032 43,000 14.6% 14.9% 9,630 582.5 8.3% (+/- 0.5) New York 19,465,197 15.0% 25.5% (+/- 0.8) 199,433 350,000 14.7% 13.7% 107,260 511.3 8.7% (+/- 0.4) North Carolina 9,656,401 17.0% 25.6% (+/- 0.7) 19,847 210,000 12.6% 8.2% 48,870 448.2 9.6% (+/- 0.4) North Dakota 683,932 13.1% 25.7% (+/- 1.0) 184 20,000 10.6% 18.7% 3,560 371.7 7.5% (+/- 0.5) Ohio 11,544,951 13.7% 26.2% (+/- 0.8) 18,099 250,000 13.8% 8.6% 65,060 443.1 10.0% (+/- 0.5) Oklahoma 3,791,508 17.0% 30.9% (+/- 0.8) 5,610 96,000 14.2% 11.9% 18,980 387.9 10.5% (+/- 0.5) Oregon 3,871,859 16.2% 18.1% (+/- 0.9) 6,795 110,000 16.2% 21.0% 21,180 322.9 7.4% (+/- 0.5) Pennsylvania 12,742,886 11.0% 25.8% (+/- 0.7) 38,282 280,000 13.8% 14.4% 78,030 377.0 9.4% (+/- 0.4) Rhode Island 1,051,302 11.4% 24.4% (+/- 0.9) 2,940 24,000 16.7% 12.9% 6,090 330.4 7.4% (+/- 0.5) South Carolina 4,679,230 20.6% 27.1% (+/- 0.9) 15,916 100,000 12.9% 7.1% 25,510 581.5 10.4% (+/- 0.5) South Dakota 824,082 13.0% 25.3% (+/- 0.9) 313 21,000 11.6% 15.2% 4,430 392.9 6.9% (+/- 0.4) Tennessee 6,403,353 14.7% 29.9% (+/- 1.2) 14,671 140,000 9.3% 12.8% 34,750 449.9 10.6% (+/- 0.7) Texas 25,674,681 24.6% 27.5% (+/- 0.9) 79,568 470,000 12.8% 13.5% 105,000 483.7 9.6% (+/- 0.5) Utah 2,817,222 13.6% 18.4% (+/- 0.7) 2,568 50,000 14.3% 17.0% 10,530 240.3 6.2% (+/- 0.4) Vermont 626,431 9.5% 19.2% (+/- 0.7) 511 13,000 17.2% 25.5% 3,950 202.2 6.5% (+/- 0.4) Virginia 8,096,604 14.1% 22.9% (+/- 1.2) 19,871 160,000 12.9% 14.5% 38,720 390.7 8.3% (+/- 0.5) Washington 6,830,038 13.8% 19.0% (+/- 0.5) 13,253 150,000 15.8% 23.0% 35,360 320.3 7.4% (+/- 0.3) West Virginia 1,855,364 13.5% 32.4% (+/- 1.0) 1,803 50,000 10.7% 5.6% 11,080 213.0 12.0% (+/- 0.6) Wisconsin 5,711,767 9.4% 22.3% (+/- 1.0) 5,192 130,000 12.8% 14.7% 30,530 410.9 7.5% (+/- 0.6) Wyoming 568,158 17.3% 23.0% (+/- 0.8) 276 15,000 14.7% 17.2% 2,680 388.2 7.2% (+/- 0.4) U.S. Total 311,591,917 16.3% N/A* 1,099,163 6,479,700 13.5% 14.8% 1,596,670 426.0 N/A* Notes ^The AAP Section on Breastfeeding, American Academy of Family Physicians, World Health Organization, United Nations Children’s Fund, and many other health organizations recommend exclusive breastfeeding for the first 6 months of life. 38 Fruits and Human Seasonal Vegetables (5 or Poverty Syphilis Tobacco West Hypertension Obesity 2008- Pneumococcal Flu Tuberculosis more servings a 2006-2008 Rates per Use Nile Virus 2005-2009 3 Yr 2010 3 Yr. Ave. Vaccination Vaccination Number of State day) 2005-2009 3 Yr Average 100,000 -Current Cases Average (95% Percentage (95% Rates 65 and Rates 65 Cases — 3 Yr Average (90% Conf Population Smokers 2010 (as Conf Interval) Conf Interval) Over 2010 and Over 2009 (95% Conf Interval) (2010) 2010 of 12/13/11) 2010 Interval) Alabama 20.3% (+/- 0.9) 5 33.9% (+/- 1.0) 32.3% (+/- 1.0) 65.6% 14.4% (+/- 1.5) 63.2% 5.5 21.9% 146 Alaska 24.1% (+/- 1.6) 0 24.3% (+/- 1.4) 25.9% (+/- 1.6) 66.5% 8.2% (+/- 1.2) 63.7% 0.4 20.4% 57 Arizona 25.4% (+/- 1.4) 42 24.7% (+/- 1.2) 25.4% (+/- 1.4) 71.8% 15.6% (+/- 1.4) 67.2% 3.5 13.5% 283 Arkansas 21.1% (+/- 0.9) 1 31.6% (+/- 1.0) 30.6% (+/- 1.2) 67.3% 15.6% (+/- 1.6) 69.6% 7.1 22.9% 78 California 28.5% (+/- 0.8) 154 25.5% (+/- 0.7) 24.8% (+/- 0.6) 62.6% 13.2% (+/- 0.5) 63.0% 5.6 12.1% 2,327 Colorado 25.0% (+/- 0.7) 7 21.2% (+/- 0.6) 19.8% (+/- 0.7)* 73.3% 10.2% (+/- 1.3) 73.4% 2.7 16.0% 71 Connecticut 28.1% (+/- 0.9) 9 25.7% (+/- 0.8) 21.8% (+/- 0.9) 69.2% 8.3% (+/- 1.2) 72.4% 2.8 13.2% 85 Delaware 22.5% (+/- 1.1) 1 29.4% (+/- 1.1) 28.0% (+/- 1.2) 70.0% 9.4% (+/- 1.3) 66.9% 1.0 17.3% 20 D.C. 32.1% (+/- 1.2) 4 27.3% (+/- 1.1) 21.7% (+/- 1.0) 65.4% 17.6% (+/- 1.9) 62.0% 22.3 14.8% 44 Florida 25.7% (+/- 0.8) 23 29.0% (+/- 0.8) 26.1% (+/- 0.9)** 69.9% 12.4% (+/- 0.7) 65.6% 6.4 17.1% 835 Georgia 24.3% (+/- 1.0) 12 29.5% (+/- 1.0) 28.7% (+/- 1.1) 64.4% 13.9% (+/- 1.0) 61.8% 8.1 17.6% 411 Hawaii 25.6% (+/- 0.9) 0 27.8% (+/- 0.9) 23.1% (+/- 0.9) 66.8% 8.9% (+/- 1.2) 73.2% 2.7 14.5% 115 Idaho 23.4% (+/- 0.9) 2 25.2% (+/- 0.9) 25.7% (+/- 1.0) 66.2% 10.6% (+/- 1.3) 60.7% 0.4 15.7% 15 Illinois 23.7% (+/- 0.9) 34 27.5% (+/- 0.9) 27.7% (+/- 1.0)** 61.9% 11.0% (+/- 0.8) 65.5% 7.0 16.9% 372 Indiana 21.8% (+/- 0.8) 9 28.5% (+/- 0.8) 29.1% (+/- 0.9)** 68.8% 12.3% (+/- 1.2) 66.4% 2.7 21.2% 90 Iowa 19.3% (+/- 0.8) 9 26.5% (+/- 0.8) 28.1% (+/- 0.9) 70.3% 9.6% (+/- 1.3) 70.4% 0.6 16.1% 48 Kansas 19.1% (+/- 0.6) 4 26.6% (+/- 0.6) 29.0% (+/- 0.8)** 68.5% 12.4% (+/- 1.5) 68.6% 0.7 17.0% 46 Kentucky 18.8% (+/- 0.9) 5 31.6% (+/- 1.0) 31.5% (+/- 1.0)** 64.6% 16.5% (+/- 1.6) 67.7% 3.2 24.8% 90 Louisiana 18.9% (+/- 0.9) 10 32.5% (+/- 0.9) 31.6% (+/- 0.9) 67.4% 17.1% (+/- 1.6) 64.3% 12.2 22.1% 200 Maine 28.4% (+/- 0.9) 0 28.1% (+/- 0.8) 26.5% (+/- 0.8)** 71.8% 11.0% (+/- 1.5) 72.0% 2.4 18.2% 8 Maryland 27.6% (+/- 0.8) 20 28.2% (+/- 0.8) 27.1% (+/- 0.8) 66.5% 8.6% (+/- 1.1) 68.7% 5.8 15.2% 220 Massachusetts 27.5% (+/- 0.7) 5 25.6% (+/- 0.6) 22.3% (+/- 0.6)** 71.2% 11.5% (+/- 1.1) 72.4% 4.3 14.1% 222 Michigan 22.2% (+/- 0.7) 33 28.7% (+/- 0.7) 30.5% (+/- 0.8)* 67.8% 12.4% (+/- 0.9) 67.5% 2.4 18.9% 184 Minnesota 21.9% (+/- 1.0) 2 21.6% (+/- 0.8) 25.3% (+/- 1.0) 70.4% 9.1% (+/- 1.1) 72.0% 2.8 14.9% 135 Mississippi 17.1% (+/- 0.8) 52 34.8% (+/- 0.8) 34.4% (+/- 0.9) 67.6% 20.5% (+/- 1.7) 66.1% 7.7 22.9% 116 Missouri 20.9% (+/- 1.0) 10 29.1% (+/- 1.1) 30.3% (+/- 1.2)** 71.2% 12.5% (+/- 1.3) 67.1% 2.5 21.1% 107 Montana 25.2% (+/- 0.9) 1 25.7% (+/- 0.8) 23.8% (+/- 0.9) 71.8% 13.1% (+/- 1.5) 65.5% 0.3 18.8% 6 Nebraska 21.8% (+/- 0.9) 28 26.1% (+/- 0.8) 27.6% (+/- 0.9) 70.9% 10.2% (+/- 1.4) 71.2% 0.7 17.2% 27 Nevada 22.7% (+/- 1.4) 16 26.3% (+/- 1.3) 25.0% (+/- 1.4) 66.6% 10.0% (+/- 1.3) 59.3% 4.9 21.3% 114 New Hampshire 28.5% (+/- 0.9) 0 26.1% (+/- 0.8) 25.6% (+/- 0.9) 71.2% 6.1% (+/- 1.1) 71.3% 1.7 16.9% 10 New Jersey 26.6% (+/- 0.8) 7 27.2% (+/- 0.7) 24.1% (+/- 0.7) 64.3% 8.9% (+/- 0.9) 65.7% 2.8 14.4% 405 New Mexico 22.4% (+/- 0.8) 4 25.0% (+/- 0.8) 25.6% (+/- 0.9) 68.6% 16.7% (+/- 1.8) 69.3% 2.6 18.5% 51 New York 26.8% (+/- 0.9) 43 27.1% (+/- 0.8) 24.7% (+/- 0.8) 66.1% 14.2% (+/- 0.8) 68.3% 5.6 15.5% 954 North Carolina 21.6% (+/- 0.6) 2 29.9% (+/- 0.6) 29.4% (+/- 0.8) 71.2% 14.4% (+/- 1.1) 69.7% 4.2 19.8% 296 North Dakota 22.1% (+/- 0.9) 4 25.4% (+/- 0.9) 28.0% (+/- 1.1) 70.9% 10.8% (+/- 1.4) 66.4% 0.5 17.4% 12 Ohio 21.5% (+/- 0.8) 21 29.1% (+/- 0.8) 29.6% (+/- 0.8) 68.5% 12.9% (+/- 0.9) 64.8% 4.6 22.5% 190 Oklahoma 15.5% (+/- 0.6) 0 31.9% (+/- 0.8) 31.4% (+/- 0.8)** 72.6% 14.1% (+/- 1.5) 70.9% 2.5 23.7% 86 Oregon 26.4% (+/- 0.9) 0 25.8% (+/- 0.8) 25.4% (+/- 1.0) 74.0% 11.7% (+/- 1.5) 65.0% 1.9 15.1% 87 Pennsylvania 24.5% (+/- 0.7) 6 28.9% (+/- 0.7) 28.5% (+/- 0.8) 70.6% 10.9% (+/- 0.8) 68.0% 2.9 18.4% 238 Rhode Island 26.2% (+/- 1.0) 1 28.3% (+/- 0.9) 24.3% (+/- 1.0)** 71.7% 10.9% (+/- 1.4) 70.3% 3.9 15.7% 26 South Carolina 19.1% (+/- 0.7) 0 31.5% (+/- 0.8) 30.9% (+/- 1.0)* 70.0% 13.1% (+/- 1.5) 67.4% 3.4 21.0% 153 South Dakota 18.3% (+/- 0.8) 2 26.9% (+/- 0.8) 28.7% (+/- 1.0) 68.0% 11.1% (+/- 1.3) 72.0% 0.5 15.4% 15 Tennessee 25.4% (+/- 1.1) 18 32.2% (+/- 1.1) 31.9% (+/- 1.2) 66.1% 14.9% (+/- 1.3) 66.6% 4.4 20.1% 193 Texas 23.9% (+/- 0.7) 26 27.2% (+/- 0.7) 30.1% (+/- 0.9)** 68.5% 16.3% (+/- 0.7) 67.2% 5.0 15.8% 1,385 Utah 22.8% (+/- 0.9) 3 20.5% (+/- 0.7) 23.4% (+/- 0.8) 68.3% 8.8% (+/- 1.1) 68.2% 2.3 9.1% 20 Vermont 30.1% (+/- 0.9) 1 25.2% (+/- 0.7) 23.5% (+/- 0.8)** 72.8% 8.9% (+/- 1.4) 71.5% 0.6 15.4% 5 Virginia 26.6% (+/- 1.1) 8 27.2% (+/- 1.0) 25.9% (+/- 1.2) 72.1% 9.2% (+/- 0.9) 68.9% 3.5 18.5% 268 Washington 25.4% (+/- 0.5) 0 25.9% (+/- 0.5) 26.4% (+/- 0.5) 72.8% 9.5% (+/- 1.1) 69.3% 4.0 15.2% 239 West Virginia 18.6% (+/- 0.8) 1 34.1% (+/- 1.0) 32.2% (+/- 1.1)* 62.4% 14.9% (+/- 1.4) 66.4% 0.3 26.8% 15 Wisconsin 23.1% (+/- 1.0) 3 26.4% (+/- 1.0) 27.4% (+/- 1.1) 73.1% 10.3% (+/- 1.2) 68.4% 0.9 19.1% 55 Wyoming 23.2% (+/- 0.8) 3 24.9% (+/- 0.8) 25.4% (+/- 0.9) 69.4% 10.3% (+/- 1.4) 65.1% 0.0 19.5% 7 U.S. Total N/A* 667 N/A* N/A* 68.8% 12.7% (+/- 0.2) 67.5% 4.5 17.3% 11,182 39 Appendix C: S tate-by-State Child and Adolescent Health Indicators Child/Adolescent Health Indicators AIDS Asthma - 2009 Immunization Gap, % 2011 Census% Uninsured, Cumulative Fruit and Vegetable High School of Children Aged 19 to State Population under 18 Cases Under Indicator - 2009 (95% Students (95% 35 Months Without All Estimates (2010) Age 13 - 2009 Conf Interval) Conf Interval) Immunizations - 2010 Yr End Alabama 4,802,740 8.9 76 25.5% (+/- 2.8) 16.3% (+/- 3.1) 28.8% Alaska 722,718 13.7 7 18.5% (+/- 1.9) 17.2% (+/- 2.2) 35.0% Arizona 6,482,505 15.0 47 20.9% (+/- 2.6) N/A 30.0% Arkansas 2,937,979 7.4 38 23.2% (+/- 2.3) 14.9% (+/- 2.6) 26.8% California 37,691,912 10.7 696 N/A N/A 31.4% Colorado 5,116,796 7.8 32 21.7% (+/- 2.6) 24.4% (+/- 2.1) 34.3% Connecticut 3,580,709 6.0 188 N/A 21.0% (+/- 2.5) 29.9% Delaware 907,135 6.0 27 N/A N/A 31.9% D.C. 617,996 5.1 192 N/A N/A 22.7% Florida 19,057,542 14.2 1,577 20.7% (+/- 1.1) 21.6% (+/- 1.3) 20.1% Georgia 9,815,210 9.9 233 26.0% (+/- 3.0) 17.1% (+/- 2.3) 33.0% Hawaii 1,374,810 2.3 17 28.3% (+/- 2.5) 17.2% (+/- 1.8) 27.1% Idaho 1,584,985 9.0 3 17.6% (+/- 1.6) 18.5% (+/- 2.0) 42.6% Illinois 12,869,257 7.6 289 22.2% (+/- 2.6) 18.3% (+/- 2.2) 27.6% Indiana 6,516,922 6.0 57 23.6% (+/- 3.4) 16.1% (+/- 2.3) 29.8% Iowa 3,062,309 7.4 13 N/A N/A 27.3% Kansas 2,871,238 7.5 16 21.1% (+/- 1.8) 20.5% (+/- 2.3) 26.0% Kentucky 4,369,356 6.8 37 24.3% (+/- 2.3) 14.2% (+/- 1.7) 35.8% Louisiana 4,574,836 9.0 134 22.4% (+/- 3.0) 13.9% (+/- 3.0) 31.0% Maine 1,328,188 4.4 8 26.3% (+/- 1.0) N/A 33.0% Maryland 5,828,289 9.2 332 26.1% (+/- 3.4) 22.5% (+/- 3.5) 35.0% Massachusetts 6,587,536 3.8 227 N/A N/A 22.8% Michigan 9,876,187 5.1 117 23.3% (+/- 1.8) 19.6% (+/- 3.5) 21.0% Minnesota 5,344,861 6.0 29 N/A N/A 28.4% Mississippi 2,978,512 13.4 58 18.2% (+/- 2.1) 21.2% (+/- 2.8) 25.4% Missouri 6,010,688 8.9 63 20.6% (+/- 1.7) 20.4% (+/- 2.5) 34.5% Montana 998,199 8.8 3 19.5% (+/- 2.5) 18.4% (+/- 2.9) 39.6% Nebraska 1,842,641 10.3 12 N/A N/A 23.4% Nevada 2,723,322 17.5 29 19.4% (+/- 2.0) 17.0% (+/- 2.2) 41.4% New Hampshire 1,318,194 5.5 10 N/A N/A 19.0% New Jersey 8,821,155 9.2 809 24.2% (+/- 2.8) 20.1% (+/- 2.9) 38.3% New Mexico 2,082,224 13.7 8 25.3% (+/- 2.5) 20.9% (+/- 3.1) 34.6% New York 19,465,197 7.9 2,438 23.2% (+/- 2.2) N/A 38.4% North Carolina 9,656,401 9.2 130 21.8% (+/- 1.9) 16.9% (+/- 1.8) 28.8% North Dakota 683,932 10.2 2 19.8% (+/- 2.0) 13.7% (+/- 1.8) 24.8% Ohio 11,544,951 8.3 151 N/A N/A 26.2% Oklahoma 3,791,508 11.9 27 21.6% (+/- 3.6) 14.8% (+/- 2.1) 38.4% Oregon 3,871,859 10.4 19 N/A N/A 33.0% Pennsylvania 12,742,886 8.2 375 22.0% (+/- 3.0) 20.4% (+/- 2.4) 24.9% Rhode Island 1,051,302 5.3 28 22.5% (+/- 1.6) 22.6% (+/- 3.1) 31.1% South Carolina 4,679,230 14.2 111 21.7% (+/- 2.9) 14.7% (+/- 2.8) 26.4% South Dakota 824,082 6.6 6 15.5% (+/- 1.9) 14.7% (+/- 3.0) 34.6% Tennessee 6,403,353 7.9 60 17.9% (+/- 1.7) 18.1% (+/- 2.1) 23.8% Texas 25,674,681 16.3 399 19.0% (+/- 1.9) 21.3% +/- 1.7) 29.9% Utah 2,817,222 11.4 20 21.4% (+/- 2.2) 18.4% (+/- 3.1) 33.3% Vermont 626,431 4.1 6 N/A 22.6% (+/- 2.1) 31.0% Virginia 8,096,604 8.3 185 N/A N/A 30.5% Washington 6,830,038 5.9 35 N/A N/A 29.1% West Virginia 1,855,364 2.7 11 25.7% (+/- 3.0) 18.2% (+/- 2.8) 37.4% Wisconsin 5,711,767 4.6 34 N/A 19.1% (+/- 2.0) 19.9% Wyoming 568,158 10.2 2 21.2% (+/- 1.6) 19.1 (+/- 1.6) 37.9% U.S. Total 311,591,917 9.8% 9,448 21.7% 18.4% 29.8% 40 Pre-Term InfantMortality % Low Tobacco: Current Obese - 2009 High Births % of - Per 1,000 Live Birthweight Obese: % of 10 to Smokers High School State School Students live births Births 2008 Babies - 2009 17 Year Olds (2007) Students 2009 (95% (95% Conf Interval) 2009 Final Final Data Final Data Conf Interval) Data Alabama 9.5 10.3 13.5% (+/- 2.4) 17.9% (+/- 3.6) 15.6 20.8% (+/- 3.0) Alaska 5.9 5.9 11.8% (+/- 2.0) 14.1% (+/- 3.1) 11.0 15.7% (+/- 2.9) Arizona 6.4 7.1 13.1% (+/- 1.9) 17.8% (+/- 4.3) 12.7 19.7% (+/- 3.0) Arkansas 7.4 8.9 14.4% (+/- 2.6) 20.4% (+/- 3.7) 13.1 20.3% (+/- 3.9) California 5.1 6.8 N/A 15.0% (+/- 5.1) 10.3 N/A Colorado 6.2 8.8 7.1% (+/- 2.2) 14.2% (+/- 4.5) 11.3 17.7% (+/- 5.0) Connecticut 6.0 8.0 10.4% (+/- 2.2) 12.5% (+/- 2.9) 10.2 17.8% (+/- 2.6) Delaware 8.4 8.6 13.7% (+/- 1.5) 13.3% (+/- 3.1) 12.5 19.0% (+/- 2.6) D.C. 10.9 10.3 N/A 20.1% (+/- 4.0) 14.2 N/A Florida 7.2 8.7 10.3% (+/- 1.1) 18.3% (+/- 5.1) 13.5 16.1% (+/- 1.4) Georgia 8.1 9.4 12.4% (+/- 2.2) 21.3% (+/- 5.1) 13.8 16.9% (+/- 2.8) Hawaii 5.5 8.4 14.5% (+/- 3.5) 11.2% (+/- 2.8) 12.6 15.2% (+/- 2.7) Idaho 5.9 6.5 8.8% (+/- 1.5) 11.8% (+/- 2.7) 10.1 14.5% (+/- 2.2) Illinois 7.1 8.4 11.9% (+/- 2.2) 20.7% (+/- 3.7) 12.4 18.1% (+/- 3.4) Indiana 6.9 8.3 12.8% (+/- 2.5) 14.6% (+/- 3.2) 11.9 23.5% (+/- 3.3) Iowa 5.7 6.7 N/A 11.2% (+/- 2.8) 11.3 N/A Kansas 7.3 7.3 12.4% (+/- 2.2) 16.2% (+/- 3.8) 11.2 16.9% (+/- 2.9) Kentucky 6.9 8.9 17.6% (+/- 2.7) 21.0% (+/- 3.6) 13.6 26.1% (+/- 4.1) Louisiana 9.1 10.6 14.7% (+/- 2.8) 20.7% (+/- 4.0) 14.7 17.6% (+/- 3.1) Maine 5.5 6.3 12.5% (+/- 0.8) 12.9% (+/- 2.8) 9.9 18.1% (+/- 1.1) Maryland 8.0 9.1 12.2% (+/- 2.5) 13.6% (+/- 3.3) 12.7 11.9% (+/- 2.4) Massachusetts 5.1 7.8 10.9% (+/- 1.8) 13.3% (+/- 3.6) 10.9 16.0% (+/- 2.2) Michigan 7.4 8.4 11.9% (+/- 1.5) 12.4% (+/- 3.1) 12.4 18.8% (+/- 2.5) Minnesota 6.0 6.5 N/A 11.1% (+/- 3.1) 10.1 N/A Mississippi 10.0 12.2 18.3% (+/- 2.6) 21.9% (+/- 3.5) 18.0 19.6% (+/- 3.0) Missouri 7.2 8.1 14.4% (+/- 2.2) 13.6% (+/- 3.1) 12.2 18.9% (+/- 3.5) Montana 6.8 7.1 10.4% (+/- 2.2) 11.8% (+/- 2.8) 10.9 18.7% (+/- 3.8) Nebraska 5.4 7.1 N/A 15.8% (+/- 3.7) 11.5 N/A Nevada 5.3 8.1 11.0% (+/- 1.9) 15.2% (+/- 4.5) 13.8 17.0% (+/- 2.4) New Hampshire 4.0 6.9 12.4% (+/- 2.7) 12.8% (+/- 2.9) 9.9 20.8% (+/- 3.2) New Jersey 5.6 8.3 10.3% (+/- 2.0) 15.4% (+/- 3.6) 12.0 17.0% (+/- 2.8) New Mexico 5.6 8.3 13.5% (+/- 2.6) 16.0% (+/- 4.2) 12.3 24.0% (+/- 2.9) New York 5.5 8.2 11.0% (+/- 1.7) 17.1% (+/- 3.7) 12.2 14.8% (+/- 2.1) North Carolina 8.2 9.0 13.4% (+/- 2.5) 18.6% (+/- 3.9) 13.0 17.7% (+/- 3.1) North Dakota 5.8 6.4 11.0% (+/- 1.6) 11.4% (+/- 2.5) 10.6 22.4% (+/- 3.1) Ohio 7.7 8.6 N/A 18.5% (+/- 4.1) 12.3 N/A Oklahoma 7.3 8.4 14.1% (+/- 2.9) 16.4% (+/- 3.5) 13.8 22.6% (+/- 4.8) Oregon 5.2 6.3 N/A 9.6% (+/- 2.7) 9.8 N/A Pennsylvania 7.4 8.3 11.8% (+/- 1.5) 15.0% (+/- 4.0) 11.5 18.4% (+/- 3.6) Rhode Island 5.9 8.0 10.4% (+/- 2.1) 14.4% (+/- 3.2) 11.4 13.3% (+/- 2.8) South Carolina 8.0 10.0 16.7% (+/- 4.5) 15.3% (+/- 3.1) 14.5 20.5% (+/- 3.0) South Dakota 8.4 5.8 9.6% (+/- 2.1) 13.2% (+/- 3.2) 10.9 23.2% (+/- 4.0) Tennessee 8.1 9.2 15.8% (+/- 2.1) 20.6% (+/- 3.7) 13.0 20.9% (+/- 4.0) Texas 6.2 8.5 13.6% (+/- 1.8) 20.4% (+/- 5.1) 13.1 21.2% (+/- 2.4) Utah 4.8 7.0 6.4% (+/- 1.9) 11.4% (+/- 3.6) 11.3 8.5% (+/- 2.4) Vermont 4.6 6.7 12.2% (+/- 1.5) 12.9% (+/- 3.4) 9.3 17.6% (+/- 1.7) Virginia 6.9 8.4 N/A 15.2% (+/- 3.2) 11.4 N/A Washington 5.4 6.3 N/A 11.1% (+/- 3.5) 10.3 N/A West Virginia 7.7 9.2 14.2% (+/- 2.4) 18.9% (+/- 3.2) 12.9 21.8% (+/- 3.2) Wisconsin 7.0 7.1 9.3% (+/- 1.4) 13.1% (+/- 2.5) 10.9 16.9% (+/- 2.7) Wyoming 7.0 8.4 9.8% (+/- 1.3) 10.2% (+/- 2.7) 11.2 22.1% (+/- 2.0) U.S. Total 6.6 8.2 N/A** N/A* 12.2 N/A** 41 Appendix D: State-by-State Other Public Health Indicators Other Public Health Indicators Health Health Health ASPR Hospital 2011 Census Professions Professions Professions Nursing Shortage Preparedness State Population Service Areas Service Areas Service Areas Estimates (2010) Program Funding Estimates Primary Care Mental Health Dental Care by State 2011 (As of 10/31/11) (As of 10/31/11) (As of 10/31/11) Alabama 4,802,740 83 49 61 -200 $5,386,508 Alaska 722,718 79 51 46 -2,300 $1,211,937 Arizona 6,482,505 144 83 145 -12,500 $7,051,765 Arkansas 2,937,979 101 43 54 -2,700 $3,486,575 California 37,691,912 579 304 335 -47,600 $28,666,533 Colorado 5,116,796 113 52 83 -10,900 $5,550,503 Connecticut 3,580,709 41 27 40 -11,100 $4,223,889 Delaware 907,135 11 7 7 -1,300 $1,406,825 D.C. 617,996 13 7 8 -3,000 $1,558,756 Florida 19,057,542 263 155 223 -32,700 $19,720,658 Georgia 9,815,210 211 87 156 -16,400 $10,449,266 Hawaii 1,374,810 30 31 26 -4,500 $1,865,852 Idaho 1,584,985 68 27 63 -800 $2,058,131 Illinois 12,869,257 260 130 172 -9,300 $11,113,877 Indiana 6,516,922 105 52 45 -8,200 $7,208,168 Iowa 3,062,309 124 63 132 -3,400 $3,668,490 Kansas 2,871,238 162 63 132 -1,000 $3,436,853 Kentucky 4,369,356 148 109 89 1,200 $4,968,989 Louisiana 4,574,836 126 101 98 100 $5,055,790 Maine 1,328,188 78 45 75 -2,500 $1,904,184 Maryland 5,828,289 56 44 39 -7,000 $6,466,757 Massachusetts 6,587,536 78 60 70 -16,100 $7,339,572 Michigan 9,876,187 220 129 152 -3,100 $11,226,706 Minnesota 5,344,861 125 50 111 -4,400 $5,990,088 Mississippi 2,978,512 110 39 104 -500 $3,592,473 Missouri 6,010,688 191 73 151 -12,900 $6,707,932 Montana 998,199 103 63 77 -500 $1,503,679 Nebraska 1,842,641 120 68 81 -2,400 $2,378,867 Nevada 2,723,322 64 26 28 -4,100 $3,151,521 New Hampshire 1,318,194 26 20 23 -3,300 $1,897,087 New Jersey 8,821,155 35 30 31 -19,600 $9,769,919 New Mexico 2,082,224 94 51 69 -3,100 $2,576,778 New York 19,465,197 196 151 136 -21,500 $12,285,085 North Carolina 9,656,401 127 81 119 -8,100 $9,910,111 North Dakota 683,932 82 48 31 -900 $1,175,614 Ohio 11,544,951 139 87 105 -12,100 $12,695,478 Oklahoma 3,791,508 174 102 100 -500 $4,302,943 Oregon 3,871,859 103 54 76 -5,300 $4,432,087 Pennsylvania 12,742,886 180 118 154 -21,100 $13,718,265 Rhode Island 1,051,302 19 16 16 -3,000 $1,634,345 South Carolina 4,679,230 97 47 68 -5,200 $5,091,363 South Dakota 824,082 88 49 54 -200 $1,330,796 Tennessee 6,403,353 124 55 135 -18,500 $6,916,279 Texas 25,674,681 444 357 250 -41,900 $25,477,218 Utah 2,817,222 60 30 52 -1,500 $3,209,463 Vermont 626,431 32 22 24 -600 $1,162,908 Virginia 8,096,604 122 78 91 -11,000 $8,620,629 Washington 6,830,038 156 107 111 -8,800 $7,295,589 West Virginia 1,855,364 104 65 73 700 $2,432,140 Wisconsin 5,711,767 117 114 81 500 $6,403,834 Wyoming 568,158 42 23 23 -1,200 $1,047,196 U.S. Total 311,591,917 6,367 3,749 4,638 -405,800 $321,736,271 42 Appendix E: State-by-State Funding Chart — HRSA FY 2011 HRSA Grants to States by Key Program Area (Selected Programs) HRSA Per Maternal & Child HRSA Total HRSA Per Capita State Primary Health Care Health Professions HIV/AIDS Capita Total Health (All Programs) Ranking (All Programs) Alabama $54,102,087 $21,065,331 $21,116,715 $28,091,600 $126,347,908 $26.31 22 Alaska $47,359,913 $1,527,627 $4,267,386 $2,006,597 $59,949,156 $82.95 1 Arizona $60,571,788 $8,571,711 $22,204,793 $27,014,377 $121,235,587 $18.70 39 Arkansas $32,708,022 $10,501,864 $17,167,251 $10,230,874 $73,515,226 $25.02 24 California $381,949,063 $68,300,813 $78,838,273 $292,207,437 $827,850,412 $21.96 33 Colorado $84,860,198 $12,537,768 $14,962,563 $27,515,783 $143,696,964 $28.08 20 Connecticut $49,643,056 $7,332,514 $9,310,135 $31,551,487 $98,247,575 $27.44 21 Delaware $8,323,410 $4,565,515 $8,239,091 $7,207,698 $28,615,714 $31.55 14 D.C. $18,937,126 $18,778,667 $26,423,021 $74,718,023 $139,185,860 N/A* N/A* Florida $131,539,715 $23,415,099 $32,096,562 $230,915,441 $421,186,942 $22.10 32 Georgia $60,742,369 $16,009,364 $29,244,126 $85,148,277 $195,112,699 $19.88 36 Hawaii $41,285,195 $6,495,215 $10,780,783 $4,388,727 $64,454,665 $46.88 2 Idaho $36,874,094 $1,179,297 $5,223,301 $2,844,760 $47,854,484 $30.19 16 Illinois $153,740,496 $21,400,071 $45,327,764 $83,815,330 $309,282,921 $24.03 27 Indiana $45,976,801 $6,754,963 $28,825,136 $16,489,766 $100,625,322 $15.44 46 Iowa $35,812,207 $6,402,090 $10,582,787 $5,379,308 $61,751,878 $20.17 34 Kansas $16,866,577 $5,768,995 $8,470,136 $4,961,942 $39,250,735 $13.67 47 Kentucky $56,659,884 $5,810,279 $15,953,808 $14,114,690 $96,796,214 $22.15 30 Louisiana $53,961,768 $12,505,960 $27,024,902 $47,789,469 $144,770,300 $31.64 13 Maine $25,531,436 $2,765,806 $11,883,951 $2,862,293 $46,016,429 $34.65 10 Maryland $41,126,516 $6,288,208 $22,631,899 $137,059,486 $209,561,015 $35.96 8 Massachusetts $108,689,802 $34,718,384 $36,666,864 $75,143,318 $256,520,190 $38.94 7 Michigan $79,688,615 $25,121,512 $34,639,241 $31,165,974 $177,946,689 $18.02 43 Minnesota $21,199,652 $11,396,717 $16,049,418 $14,454,957 $68,959,213 $12.90 49 Mississippi $50,531,598 $4,984,886 $13,307,058 $16,558,324 $88,436,075 $29.69 18 Missouri $74,164,643 $17,494,367 $20,526,748 $29,915,431 $148,876,171 $24.77 25 Montana $21,524,480 $5,149,329 $7,761,669 $1,963,031 $40,961,605 $41.04 5 Nebraska $18,870,815 $6,844,582 $8,576,317 $3,620,441 $40,733,955 $22.11 31 Nevada $10,086,736 $2,670,292 $4,326,524 $16,230,447 $34,763,422 $12.77 50 New Hampshire $10,345,560 $1,426,320 $6,782,895 $2,304,213 $22,335,235 $16.94 44 New Jersey $51,191,495 $7,660,665 $18,783,377 $83,168,667 $162,225,986 $18.39 41 New Mexico $71,610,005 $3,513,272 $11,288,971 $5,768,340 $94,041,564 $45.16 3 New York $170,483,154 $34,783,045 $60,150,403 $348,041,238 $617,057,839 $31.70 12 North Carolina $84,174,154 $12,530,770 $27,524,584 $54,115,039 $181,940,453 $18.84 37 North Dakota $4,429,614 $3,443,022 $2,884,283 $553,787 $15,227,478 $22.26 29 Ohio $77,761,993 $41,274,880 $34,312,935 $35,117,511 $292,343,980 $25.32 23 Oklahoma $30,906,416 $3,901,603 $23,133,618 $10,722,070 $70,897,793 $18.70 39 Oregon $81,190,808 $4,002,635 $15,192,421 $12,637,274 $115,271,624 $29.77 17 Pennsylvania $66,635,447 $54,206,597 $41,385,877 $87,559,305 $256,684,149 $20.14 35 Rhode Island $19,691,395 $2,385,199 $7,893,620 $6,458,328 $36,593,542 $34.81 9 South Carolina $51,675,057 $4,006,463 $19,119,437 $36,221,140 $113,727,303 $24.30 26 South Dakota $11,181,241 $2,822,642 $5,476,728 $1,273,908 $23,859,070 $28.95 19 Tennessee $71,807,549 $20,167,677 $20,361,265 $36,652,503 $152,442,292 $23.81 28 Texas $161,684,595 $46,048,085 $56,731,206 $148,897,665 $418,058,649 $16.28 45 Utah $20,247,101 $8,354,820 $14,908,364 $6,007,745 $50,963,666 $18.09 42 Vermont $12,507,558 $1,559,374 $4,443,147 $1,473,998 $20,750,922 $33.13 11 Virginia $76,845,726 $12,026,161 $18,829,813 $41,142,447 $152,245,201 $18.80 38 Washington $99,667,041 $17,528,082 $15,143,116 $78,674,879 $214,720,935 $31.44 15 West Virginia $53,810,876 $3,181,841 $12,077,846 $3,403,152 $75,730,030 $40.82 6 Wisconsin $26,193,458 $16,098,561 $20,229,004 $13,305,945 $78,053,432 $13.67 47 Wyoming $17,235,265 $961,816 $2,998,793 $1,114,567 $23,419,069 $41.22 4 U.S. TOTAL $3,094,603,570 $678,240,756 $1,032,079,925 $2,339,979,009 $7,401,095,538 $23.75** N/A** *D.C. was not included in the per capita rankings because total funding for D.C. includes funds for a number of national organizations. **The US total reflects HRSA grants to all states and D.C. 43 Appendix F: State-by-State Funding Chart — CDC CDC FUNDING BY STATE Agency Chronic for Toxic Birth Disease Section 317 PPHF/Other Substances Defects Environ- Infectious Prevention/ Heart Vaccine for Immuniza- State Affordable and and Devel- Cancer Diabetes mental HIV/AIDS Diseases (All Health Disease Children tion Care Act Disease opmental Health Other) Promotion Program Registry Disabilities (All Other) (ATSDR) Alabama $4,491,074 $0 $551,055 $5,483,915 $1,796,051 $512,407 $164,043 $376,022 $5,167,179 $55,388,691 $3,309,014 $844,286 Alaska $2,920,582 $264,250 $456,933 $9,439,241 $623,499 $514,044 $0 $435,420 $1,615,950 $10,838,232 $1,120,749 $393,987 Arizona $5,367,906 $255,065 $1,839,532 $5,560,231 $264,587 $220,332 $537,316 $339,654 $6,091,731 $80,154,471 $5,088,873 $693,366 Arkansas $5,878,794 $230,787 $1,776,692 $3,797,656 $739,584 $427,557 $0 $985,564 $2,201,586 $39,795,202 $1,982,446 $408,341 California $41,376,896 $669,864 $3,460,051 $15,199,092 $3,523,201 $3,586,866 $5,621,895 $841,818 $71,146,478 $508,084,654 $23,527,721 $3,230,051 Colorado $6,560,347 $255,150 $3,129,939 $7,363,948 $1,249,821 $1,208,879 $224,981 $315,204 $8,040,563 $42,653,709 $4,271,837 $1,620,970 Connecticut $6,380,728 $435,189 $195,720 $2,633,368 $535,946 $214,344 $1,031,132 $350,000 $7,929,325 $33,188,107 $2,029,307 $1,809,133 Delaware $1,327,645 $0 $322,047 $2,170,288 $188,864 $347,337 $0 $8,384 $2,431,768 $10,418,907 $684,782 $397,774 D.C. $7,531,470 $1,769,368 $6,968,143 $2,940,316 $5,300,105 $1,697,111 $2,342,637 $851,381 $20,403,268 $8,496,504 $1,954,092 $3,161,642 Florida $8,521,978 $697,876 $795,437 $8,284,288 $1,219,932 $849,416 $1,420,113 $1,071,106 $33,077,364 $189,989,369 $10,596,079 $348,975 Georgia $9,473,287 $274,661 $159,909 $10,479,056 $7,832,590 $1,212,149 $1,707,271 $2,117,198 $14,701,282 $135,952,153 $6,305,521 $3,846,491 Hawaii $4,022,922 $0 $216,996 $1,776,730 $232,679 $295,998 $700,887 $147,267 $2,867,739 $14,087,536 $1,551,016 $379,324 Idaho $1,199,777 $223,879 $137,801 $2,293,492 $40,000 $276,946 $101,878 $367,070 $968,203 $20,081,513 $1,371,551 $198,910 Illinois $10,917,637 $670,531 $6,036,117 $9,707,170 $5,090,150 $2,124,898 $1,178,012 $355,108 $19,913,910 $139,513,671 $7,256,692 $2,047,812 Indiana $3,443,923 $0 $205,650 $2,930,870 $183,620 $352,258 $965,182 $0 $4,015,350 $65,696,959 $1,984,348 $384,537 Iowa $7,713,019 $0 $2,464,637 $4,647,697 $1,018,823 $189,288 $851,507 $569,600 $2,402,321 $25,077,633 $2,118,483 $700,463 Kansas $5,429,114 $0 $375,000 $3,504,519 $1,284,566 $768,951 $593,984 $911,406 $1,908,165 $24,031,345 $2,313,917 $377,391 Kentucky $3,187,224 $0 $343,216 $4,976,718 $638,132 $1,113,584 $920,077 $480,000 $2,329,878 $44,492,516 $2,439,464 $554,505 Louisiana $3,506,072 $343,969 $415,763 $3,786,793 $1,574,265 $133,148 $1,269,927 $519,650 $10,105,178 $67,213,177 $1,655,487 $502,809 Maine $5,855,468 $0 $157,334 $3,236,516 $684,892 $302,353 $1,028,595 $1,101,229 $2,230,943 $10,461,885 $1,837,645 $292,328 Maryland $9,122,909 $69,673 $6,245,908 $6,033,030 $5,323,288 $521,429 $2,508,390 $538,295 $17,008,852 $60,974,411 $3,711,870 $5,031,533 Massachusetts $15,796,254 $406,895 $1,827,650 $4,988,769 $3,665,791 $1,205,488 $1,645,047 $1,695,325 $15,072,474 $60,252,712 $4,249,896 $1,914,304 Michigan $6,982,015 $419,276 $1,564,464 $13,689,835 $3,101,689 $2,030,232 $1,695,947 $990,415 $10,792,442 $90,804,476 $6,435,185 $1,210,618 Minnesota $11,621,529 $440,860 $953,665 $8,688,311 $1,947,584 $819,133 $2,167,963 $1,202,289 $4,454,245 $36,703,085 $4,069,793 $2,525,388 Mississippi $2,692,816 $0 $138,246 $3,479,496 $219,822 $347,461 $918,241 $3,918,218 $5,346,325 $43,353,731 $2,465,128 $206,162 Missouri $5,061,104 $335,895 $848,413 $5,978,412 $1,605,020 $421,537 $1,121,300 $1,321,743 $5,974,272 $56,417,831 $3,516,836 $1,053,490 Montana $2,434,986 $2,490,094 $554,998 $3,675,061 $40,000 $637,840 $796,924 $1,239,472 $1,452,752 $7,418,976 $880,697 $314,205 Nebraska $3,536,140 $0 $136,100 $5,493,110 $615,146 $344,259 $139,750 $492,679 $1,847,808 $21,377,061 $1,607,380 $627,774 Nevada $2,271,622 $0 $411,018 $3,662,328 $810,000 $265,952 $591,697 $125,267 $3,443,287 $33,236,067 $1,550,984 $551,352 New Hampshire $2,981,122 $303,659 $324,900 $3,494,997 $215,251 $406,772 $840,053 $0 $1,532,897 $8,336,866 $966,676 $631,077 New Jersey $5,176,702 $528,292 $6,825,976 $4,362,351 $228,612 $485,355 $966,049 $184,069 $21,296,757 $75,849,599 $2,866,198 $465,258 New Mexico $6,865,605 $999,758 $130,144 $4,097,542 $923,959 $514,127 $1,225,836 $188,812 $2,835,700 $35,091,101 $2,147,898 $1,512,433 New York $26,502,630 $993,511 $5,180,365 $13,047,024 $8,037,592 $887,027 $3,960,889 $1,709,050 $91,949,439 $221,994,356 $14,872,933 $8,568,837 North Carolina $13,253,683 $339,141 $3,602,676 $7,248,411 $3,051,911 $1,326,269 $1,512,355 $1,894,270 $8,204,907 $97,361,800 $4,970,285 $708,168 North Dakota $1,256,799 $0 $355,703 $2,030,037 $382,159 $319,835 $99,757 $336,875 $941,206 $5,688,437 $818,187 $398,116 Ohio $4,607,032 $496,592 $500,782 $5,698,439 $1,225,482 $1,787,338 $1,194,929 $953,063 $7,036,103 $98,675,172 $5,059,594 $3,766,212 Oklahoma $6,050,780 $0 $327,750 $3,861,611 $602,496 $920,403 $838,050 $241,741 $3,521,493 $56,917,111 $2,726,703 $430,583 Oregon $5,556,851 $557,772 $662,365 $5,536,369 $638,844 $817,980 $1,928,125 $342,103 $3,881,557 $31,959,508 $2,863,605 $1,747,474 Pennsylvania $5,858,209 $459,685 $1,409,463 $5,485,405 $1,701,219 $676,819 $1,094,579 $0 $19,307,281 $107,177,167 $6,977,893 $1,345,117 Rhode Island $2,355,850 $0 $712,237 $2,350,004 $401,458 $675,997 $1,419,372 $335,527 $2,176,427 $13,500,850 $927,932 $720,997 South Carolina $9,233,726 $0 $1,478,538 $5,502,715 $2,218,158 $599,547 $261,483 $1,042,216 $7,658,479 $48,176,016 $2,954,250 $1,005,586 South Dakota $1,774,653 $0 $122,472 $3,723,079 $39,959 $229,249 $0 $0 $1,019,538 $9,172,505 $690,695 $376,936 Tennessee $4,019,362 $280,788 $1,256,873 $2,100,332 $532,319 $315,033 $500,000 $100,044 $6,435,558 $72,384,462 $3,694,035 $1,959,438 Texas $18,468,737 $595,070 $1,567,847 $9,727,859 $2,466,449 $881,488 $1,341,118 $316,997 $35,961,752 $368,470,821 $17,472,175 $1,250,056 Utah $5,202,513 $288,573 $2,251,692 $5,325,001 $593,373 $762,511 $396,000 $886,949 $1,711,177 $22,773,277 $2,421,979 $703,849 Vermont $3,999,573 $0 $150,000 $1,749,735 $490,768 $312,975 $915,735 $24,771 $1,601,371 $6,055,559 $868,184 $552,453 Virginia $5,638,859 $349,319 $396,274 $5,199,195 $1,628,866 $321,678 $765,444 $785,691 $8,325,368 $56,289,087 $3,468,518 $1,307,863 Washington $11,812,063 $540,552 $220,257 $9,807,826 $1,618,858 $1,524,240 $3,231,903 $1,000,366 $7,331,703 $101,108,135 $4,088,849 $1,232,033 West Virginia $6,612,483 $0 $0 $5,403,347 $175,289 $819,155 $396,000 $570,562 $1,812,622 $17,786,674 $1,052,442 $354,888 Wisconsin $10,694,466 $517,638 $992,837 $4,610,758 $950,171 $935,854 $1,599,909 $337,256 $4,279,201 $45,571,882 $3,137,509 $966,057 Wyoming $1,871,534 $0 $141,924 $1,367,789 $175,000 $315,576 $0 $0 $906,856 $5,728,464 $719,981 $590,204 U.S. TOTAL $364,418,470 $17,503,632 $71,299,509 $277,630,082 $79,647,840 $38,776,425 $56,732,282 $34,917,146 $524,668,030 $3,442,223,433 $197,653,314 $66,221,556 44 Public Influenza Preventive Public Sexually Health CDC Injury Nutrition/ Occupa- (including Health Health CDC Per School Transmitted Prepared- Tuberculosis CDC Total (All Per Prevention Physical tional Safety supple- Service Scientific Tobacco Capita Health Diseases ness and Elimination Categories) Capita and Control Activity & Health mental Block Services 2011 (STD) Emergency Ranking funding) Grants (BRFSS) Response $543,390 $0 $1,354,873 $0 $1,299,655 $196,750 $437,071 $2,531,682 $1,326,289 $8,585,696 $1,069,255 $95,428,398 $19.87 30 $632,047 $0 $86,561 $0 $262,961 $121,141 $207,671 $401,442 $1,662,134 $5,169,600 $399,438 $37,565,882 $51.98 1 $1,010,519 $0 $896,837 $0 $934,962 $103,843 $720,000 $1,249,811 $1,281,398 $12,202,947 $1,379,549 $126,192,930 $19.47 33 $327,659 $198,732 $0 $98,048 $930,442 $0 $679,698 $928,010 $1,096,919 $6,490,184 $536,059 $69,509,960 $23.66 18 $9,077,880 $304,641 $5,340,304 $0 $5,504,967 $185,349 $2,960,286 $12,558,750 $2,827,932 $61,558,437 $16,232,315 $796,819,448 $21.14 25 $3,995,468 $683,146 $2,732,632 $0 $1,036,423 $140,091 $869,660 $1,756,271 $1,253,296 $9,397,930 $543,390 $99,303,655 $19.41 35 $416,711 $23,208 $657,589 $0 $1,111,658 $344,113 $592,957 $831,309 $1,009,696 $7,697,107 $449,685 $69,866,332 $19.51 31 $310,217 $5,000 $0 $68,532 $145,956 $0 $223,837 $350,498 $669,136 $5,522,932 $281,176 $25,875,080 $28.52 9 $1,061,078 $240,901 $1,658,772 $188,088 $680,676 $111,138 $3,143,690 $2,462,371 $2,916,500 $12,330,138 $577,216 $88,786,605 N/A N/A $3,113,286 $0 $1,587,841 $0 $2,500,964 $69,544 $1,438,883 $3,649,940 $1,493,816 $27,257,909 $7,277,795 $305,261,911 $16.02 46 $3,401,924 $151,960 $855,907 $59,571 $2,883,050 $76,980 $819,347 $4,044,678 $1,090,946 $18,636,887 $2,669,663 $228,752,481 $23.31 21 $299,856 $331,902 $0 $0 $592,497 $104,818 $234,984 $364,093 $800,128 $5,439,616 $750,636 $35,197,624 $25.60 12 $159,880 $0 $0 $0 $288,034 $97,996 $482,792 $396,850 $1,701,438 $5,064,052 $177,962 $35,630,024 $22.48 22 $3,993,832 $0 $2,260,348 $298,417 $2,120,278 $89,387 $1,145,935 $3,922,941 $1,064,167 $28,062,062 $2,755,941 $250,525,016 $19.47 33 $742,055 $150,000 $103,575 $0 $1,308,717 $80,722 $243,845 $1,682,938 $1,472,868 $11,138,909 $682,466 $97,768,792 $15.00 48 $1,259,040 $28,734 $1,725,749 $0 $845,962 $202,127 $208,372 $682,187 $1,011,630 $7,310,155 $352,894 $61,380,321 $20.04 29 $864,988 $7,000 $0 $0 $725,326 $226,577 $195,344 $823,327 $1,285,389 $6,595,020 $408,412 $52,629,741 $18.33 36 $1,504,002 $24,625 $689,453 $0 $1,036,693 $280,439 $259,625 $939,934 $1,427,307 $8,672,367 $702,061 $77,011,820 $17.63 41 $608,683 $586,208 $175,417 $0 $2,205,415 $94,312 $153,188 $1,999,683 $996,729 $8,735,663 $1,283,459 $107,864,995 $23.58 20 $357,159 $0 $100,000 $0 $676,899 $91,622 $207,016 $278,245 $1,143,175 $4,951,269 $176,514 $35,171,087 $26.48 10 $4,133,961 $0 $6,729,139 $896,821 $1,508,669 $389,567 $519,896 $3,131,749 $1,222,751 $14,675,178 $2,203,605 $152,500,924 $26.17 11 $2,205,176 $2,387,641 $2,492,004 $0 $2,081,371 $112,706 $165,084 $2,060,318 $1,983,559 $14,913,602 $1,111,661 $142,233,727 $21.59 24 $3,826,157 $878,194 $2,789,011 $0 $3,035,244 $314,041 $1,011,438 $2,766,302 $2,295,644 $16,712,103 $1,038,151 $174,382,879 $17.66 40 $1,537,645 $585,050 $1,523,759 $0 $1,981,465 $142,777 $580,001 $1,079,000 $1,133,740 $11,430,546 $1,067,824 $96,655,652 $18.08 39 $348,489 $0 $0 $0 $1,109,595 $87,420 $594,589 $1,282,766 $1,099,391 $6,419,473 $749,216 $74,776,585 $25.11 13 $1,988,646 $507,000 $0 $0 $2,029,587 $85,926 $0 $2,181,066 $1,156,517 $10,717,722 $584,517 $102,906,834 $17.12 43 $370,152 $775,580 $107,000 $0 $500,799 $146,737 $213,700 $248,017 $959,869 $4,973,310 $180,789 $30,411,958 $30.47 7 $510,330 $0 $115,200 $0 $1,254,468 $85,215 $215,986 $434,579 $1,213,833 $5,150,909 $213,427 $45,411,154 $24.64 16 $243,043 $5,000 $0 $0 $308,678 $132,068 $173,618 $694,721 $857,089 $6,492,738 $573,577 $56,400,106 $20.71 26 $152,806 $5,000 $115,200 $0 $1,318,562 $114,471 $168,105 $257,118 $1,044,019 $5,390,877 $231,862 $28,832,290 $21.87 23 $1,674,222 $5,000 $804,866 $161,078 $2,231,266 $147,634 $842,840 $3,148,312 $1,265,532 $16,334,853 $3,381,207 $149,232,028 $16.92 44 $404,234 $550,942 $677,904 $0 $1,183,460 $130,786 $254,468 $561,639 $1,133,145 $6,348,426 $420,449 $68,198,368 $32.75 5 $6,254,499 $2,122,210 $3,257,685 $0 $5,307,171 $115,110 $1,645,367 $9,247,988 $2,763,936 $38,848,567 $6,023,325 $473,289,511 $24.31 17 $5,047,383 $1,734,111 $2,011,355 $161,821 $2,312,573 $136,857 $816,340 $2,484,203 $1,760,684 $14,998,703 $1,891,520 $176,829,426 $18.31 37 $392,142 $0 $0 $0 $196,165 $82,720 $570,000 $243,494 $1,116,470 $5,063,379 $159,325 $20,450,806 $29.90 8 $3,093,519 $0 $1,702,065 $0 $3,479,236 $78,863 $432,156 $3,300,905 $1,575,449 $18,080,925 $1,174,948 $163,918,804 $14.20 50 $943,683 $0 $74,999 $0 $731,559 $85,177 $302,975 $908,239 $1,806,600 $7,509,542 $742,304 $89,543,799 $23.62 19 $1,660,625 $5,000 $869,538 $0 $569,615 $157,714 $207,301 $1,012,085 $1,094,341 $7,960,361 $616,701 $70,645,834 $18.25 38 $4,932,813 $744,138 $1,997,905 $578,213 $3,668,265 $75,043 $514,762 $5,119,415 $1,312,068 $20,758,562 $1,355,582 $192,549,603 $15.11 47 $1,112,095 $0 $0 $0 $485,827 $81,027 $207,700 $304,621 $1,144,904 $5,302,058 $319,722 $34,534,605 $32.85 4 $699,924 $294,873 $0 $0 $1,027,610 $131,853 $533,690 $1,326,141 $1,609,109 $9,321,351 $1,309,057 $96,384,322 $20.60 27 $356,310 $0 $0 $0 $180,390 $138,062 $520,170 $275,330 $1,445,725 $5,048,874 $238,389 $25,352,336 $30.76 6 $942,160 $0 $176,095 $570,000 $1,263,217 $65,643 $530,616 $2,180,985 $1,281,398 $10,550,748 $1,483,256 $112,622,362 $17.59 42 $3,158,658 $102,140 $2,141,598 $0 $3,298,914 $95,815 $1,042,379 $7,138,335 $1,795,474 $36,740,115 $9,405,307 $523,439,104 $20.39 28 $807,119 $0 $1,224,795 $158,194 $736,100 $124,750 $5,530 $458,077 $1,204,090 $6,571,486 $282,821 $54,889,856 $19.48 32 $76,550 $0 $0 $0 $208,954 $65,043 $218,895 $178,132 $1,140,226 $5,031,972 $153,000 $23,793,896 $37.98 2 $2,726,596 $0 $1,872,164 $0 $1,728,151 $75,098 $1,684,273 $2,270,873 $1,134,801 $18,866,451 $1,322,353 $116,156,922 $14.35 49 $1,519,356 $173,478 $2,271,984 $0 $1,057,287 $159,022 $919,365 $3,307,686 $1,409,523 $12,486,172 $1,605,229 $168,425,887 $24.66 15 $1,290,213 $410,234 $291,821 $118,751 $684,866 $0 $648,469 $688,170 $1,170,995 $5,216,593 $318,155 $45,821,729 $24.70 14 $2,498,116 $17,422 $395,143 $0 $1,507,398 $108,143 $709,661 $953,489 $1,227,786 $11,310,910 $477,245 $93,798,851 $16.42 45 $62,558 $0 $0 $0 $173,717 $130,141 $199,988 $222,754 $1,008,832 $5,027,379 $189,938 $18,832,635 $33.15 3 $88,648,854 $14,039,070 $53,867,088 $3,357,534 $74,251,714 $6,412,378 $31,673,563 $101,321,469 $69,898,393 $625,072,765 $79,530,348 $6,319,728,895 $20.28 45 Endnotes 1 nstitute of Medicine. The Future of the Public’s Health in I 11 Mays GP and Smith SA. “Evidence Links Increases the 21st Century. Washington, D.C, 2003. U.S. Centers in Public Health Spending to Declines in Prevent- for Disease Control and Prevention. Public Health’s able Health.” Health Affairs. 201l. 30:8. http:// Infrastructure — A Status Report. Atlanta, Georgia, 2001. content.healthaffairs.org/content/30/8/1585.ab- Trust for America’s Health. Blueprint for a Healthier stract (accessed March 2012). America: Modernizing the Federal Public Health Sys- 12 “Median Compensation Levels for Primary and Spe- tem to Focus on Prevention and Preparedness. 2008. cialty Care Physicians.” MGMA Physician Compensa- 2 Adjusted for inflation. tion and Production Survey, 2011 based on 2010 data. 3 udget Cuts Continue to Affect the Health of Americans: Up- B http://www.mgma.com/physcomp/ (accessed March date November 2011. Washington, D.C.: Association of 2012). State and Territorial Health Officials, November 2011. 13 ays GP and Smith SA. “Geographic Variation in M 4 udget Cuts Continue to Affect the Health of Americans: Up- B Public Health Spending,” 2009. date November 2011. Washington, D.C.: Association of 14 Ibid. State and Territorial Health Officials, November 2011. 15 Ibid. 5 Ibid. 16 Budget Cuts Continue to Affect the Health of Americans: 6 ealth Resources and Services Administration. H Update November 2011. Washington, D.C.: Associa- “About HRSA.” U.S. Department of Health and tion of State and Territorial Health Officials, No- Human Services. http://www.hrsa.gov/about/de- vember 2011. fault.htm. (accessed January 23, 2008). 17 Ibid. 7 rust for America’s Health. Public Health Leadership T 18 As required by the Massachusetts Department of Envi- Initiative An Action Plan for Healthy People in Healthy Com- ronmental Protection, Bureau of Waste Site Cleanup. munities in the 21st Century. Washington, D.C.: Trust for America’s Health, March 22, 2006. http:// 19 3-4-50: Chronic Disease Deaths in San Diego County, healthyamericans.org/policy/files/ActionPlan.pdf 2000-2009. Nick Macchione and Wilma Wooten, The “Action Plan” has been signed onto by a range of Health and Human Services Agency, County of public health experts, including Rachel Block, United San Diego, CA: http://www.sdcounty.ca.gov/hhsa/ Hospital Fund; Dr. Georges Benjamin, American Pub- programs/phs/documents/CHS-3-4-50County- lic Health Association; Dr. Jo Ivey Boufford, New York Brief_2011.pdf (accessed January 19, 2012). University Wagner; Shannon Brownlee, New America 20 Economic Impacts of Chronic Disease (2010), Nick Mac- Foundation; Maureen Byrnes, Human Rights Fund chione and Wilma Wooten, Health and Human Ser- (formerly with The Pew Charitable Trusts); Dr. Law- vices Agency, County of San Diego, CA rence Deyton, Veterans Health Administration; Dr. 21 Live Well, San Diego! Building Better Health. 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Warner, University of Michigan. 24 Patchwork of Progress: Changes in Overweight and A 8 rist B.. “Public Health and National Security: The F Obesity Among California 5th-, 7th-, and 9th-Graders, Critical Role of Increased Federal Support.” Health Af- 2005-2010. Babey SH, Wolstein J, Diamant AL, Bloom fairs 21, no. 6 (November/December 2002): 117-130. A, Goldstein H. UCLA Center for Health Policy Re- search and California Center for Public Health Advo- 9 rust for America’s Health. Public Health Leadership T cacy, 2011. http://www.healthpolicy.ucla.edu/pubs/ Initiative, 2006. files/PatchworkStudy.pdf(accessed January 2012). 10 eyer J. and Weiselberg L. “County and City M Health Departments: The Need for Sustainable Funding and the Potential Effect of Health Care Reform on their Operations.” Health Management Associates, A Report for the Robert Wood Johnson Foundation and the National Association of County & City Health Officials. 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