Introduction

The America’s Health Rankings® Annual Report is the longest running state-by-state analysis of the nation’s health. First published in 1990, America’s Health Rankings has provided an opportunity to track short- and long-term public health successes as well as identify current and emerging challenges at the state and national levels. This year, as the nation continues to grapple with the effects of the COVID-19 public health crisis, the United Health Foundation remains committed to providing data-driven insights that can help build healthier communities across the country.
This year’s 2021 Annual Report reveals a complex picture of the nation’s health and provides insights into the early effects of the COVID-19 pandemic on Americans’ health and well-being. The Annual Report highlights a dramatic increase in the U.S. death rate, as well as contrasting reversals of longer-term trends across several measures.
The report finds that the COVID-19 pandemic has had a severe impact across the country, as the nation experienced a 17% increase between 2019 and 2020 in the overall U.S. death rate, according to an America’s Health Rankings analysis of the latest provisional data from the Centers for Disease Control and Prevention (CDC). The report further finds notable reversals of long-term trends in some measures during the pandemic, including a significant increase in the number of Americans reporting their health was very good or excellent. However, Americans continue to experience large disparities by geography, race and ethnicity, education and other factors, with new data that reinforce the broad, deep and persistent disparities highlighted in the 2021 Health Disparities Report.
The Annual Report underscores well-known challenges in some measures of behavioral and mental health while highlighting unexpected reversals of trends in others. Lastly, this year’s report reveals that during the early part of the pandemic, flu vaccinations and the number of primary care and mental health providers reached their highest levels since America’s Health Rankings began tracking the measures. Not all states benefited equally, as these rates varied significantly by geography.
This year’s America’s Health Rankings does not include overall state rankings out of the shared understanding that the country faces ongoing challenges due to the COVID-19 pandemic. The report, however, still provides rankings for individual measures that help in monitoring a state's progress on key health indicators. Community leaders and advocates can use this year’s report to bring into focus opportunities to build healthier communities and to address issues caused by or exacerbated by the pandemic.
The Annual Report was developed in partnership with the American Public Health Association (APHA). The United Health Foundation is pleased to partner with the APHA as a champion for the health of all people and all communities. The United Health Foundation’s focus on improving health and health care in communities across the country closely aligns with the APHA’s mission to improve the health of the public and achieve equity in health status.
Objective
America’s Health Rankings’ objective is to inform and drive action to build healthier communities by offering credible, trusted data for improving health and health care. To achieve this, a comprehensive set of measures were analyzed to assess the health of populations across the nation. The report uses a wealth of reputable data sources to produce a combination of key health-related measures across categories of health determinants and health outcomes, including:
Eighty-one measures. This is a combination of 50 composite measures used in the scoring of states as well as 31 additional measures used to track current and emerging health issues at state and national levels. The Annual Report leveraged the most recent data available for each measure. 
Five categories of health. These include health outcomes and four categories that are determinants of health: social and economic factors, physical environment, behaviors and clinical care.
Thirty data sources. The data included in this report are from many different sources, including the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System, the U.S. Department of Agriculture’s Household Food Security in the United States report and the U.S. Census Bureau’s Current Population Survey.
Model for Measuring America’s Health
America’s Health Rankings is built upon the World Health Organization’s definition of health: “Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.”
The America’s Health Rankings Annual Report aims to improve population health by:
Presenting a holistic view of health. This report goes beyond measures of clinical care and health behaviors by considering social, economic and physical environment measures to reflect the growing understanding of the impact of social determinants on health.
Providing a benchmark for states. Each year the report presents trends, strengths, challenges and highlights for every state. With the America’s Health Rankings Annual Report’s 32 years of data, public health advocates can monitor health trends over time and compare their state with neighboring states and the nation. Every state has its strengths and challenges. It is important to consider the measures collectively, as each measure does not stand alone but rather influences and is influenced by other measures of health and everyday life. 
Stimulating action. The report is intended to drive change and improve health by promoting data-driven discussions among individuals, community leaders, public health workers, policymakers and the media. States can incorporate the report into their annual review of programs, and many organizations use the report as a reference when assigning goals for health-improvement plans.
Highlighting disparities. The report shows differences in health between states and among population groups at state and national levels, with groupings based on age, gender, race and ethnicity, educational attainment and income. These analyses often reveal differences among groups that national or state aggregate data may mask.
Impact of COVID-19
According to the Centers for Disease Control and Prevention (CDC), the COVID-19 pandemic has claimed nearly 750,000 lives across the country as of November 3, 2021 and affected countless others. The pandemic has disproportionately affected certain racial and ethnic groups, reflecting some of the longstanding disparities that persist in many of the measures analyzed in the Annual Report. 
Provisional Mortality Trends
According to the America’s Health Rankings’ analysis of the CDC’s provisional mortality data, deaths from all causes (all-cause mortality) increased 17% from 715.2 to 835.4 deaths per 100,000 population between 2019 and 2020. The most recent provisional 2021 data showed an even larger increase of 21% from pre-pandemic levels, from 715.2 to 865.6 deaths per 100,000 population between 2019 and the 12 months ending on March 31, 2021.
Between 2019 and 2020, all-cause mortality increased in all states, led by 29% in New York (616.2 to 797.1), 27% in New Jersey (657.3 to 834.4), 23% in the District of Columbia (703.2 to 862.3) and 22% in Louisiana (857.0 to 1,044.7). The smallest increases were 3% in Hawaii (573.3 to 588.0), 4% in Maine (759.7 to 787.2) and 5% in New Hampshire (700.0 to 737.7).
According to a CDC report featuring 2020 provisional mortality data, COVID-19 was the third-leading cause of death in the country, accounting for nearly 378,000 deaths. Further, the impact of the pandemic was not experienced equally in 2020. Death rates with COVID-19 listed as an underlying or contributing cause were highest among the American Indian/Alaska Native population (187.8 deaths per 100,000), males (115.0) and adults ages 85 and older (1,797.8). Death rates among the Hispanic population (164.3), the Black population (151.1) and the Hawaiian/Pacific Islander population (122.3) also exceeded the national rate (91.5) in 2020.
Meanwhile, COVID-19 vaccination rates in the U.S. continue to climb with the Food and Drug Administration approvals of vaccines for children ages 12-17, and more recently children ages 5-11. As of November 14, 2021, 58.8% of the U.S. population had been fully vaccinated. The America’s Health Rankings website contains state and national data for COVID-19 vaccination rates, case rates and hospitalization rates. This year, provisional mortality data through the first quarter of 2021 were added to the COVID-19 Report, available on the website. In addition, the website has a library of health topics featuring conditions identified as risk factors for more severe illness or death from COVID-19 as well as other related measures.
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