America’s Health Rankings: Lessons from the healthiest state

The “2019 America’s Health Rankings Annual Report,” released in December by the United Health Foundation, examines 30 years of progress on U.S. health. The report also ranks states by health, tracking over 30 measures, including violent crime, preventable hospitalizations and public health funding. In this guest post, United Health Foundation talks with Vermont’s health commissioner on why his state was named the healthiest.

Vermont took the top spot in United Health Foundation’s “2019 America’s Health Rankings Annual Report” – but that’s no surprise. The Green Mountain State has been ranked among the top five every year since 2003. What is Vermont’s secret? And what are best practices that other states can adopt? According to Vermont Commissioner of Health Mark Levine, MD, the state’s success can be attributed to three factors: commitment, collaboration and constructive criticism.

Commitment to public health
“Vermont has a population and a government that is traditionally very supportive of public health practices and policies,” Levine said. “This is evidenced by legislative initiatives and state oversight that has a bias for public health, including in environmental regulation. Equally, if not more important, is public acceptance of our messaging, education and outreach. People in Vermont want to be healthy and capitalize on the healthy environment we enjoy.”

Case in point: Vermont ranks fourth in the nation in air quality and has the second-lowest rate of violent crime in the “2019 America’s Health Rankings Annual Report.” Those are just two key social and environmental factors that influence public health.

Vermont also ranks third for policy measures, with the fourth-highest adolescent immunization rate and third-lowest rate of uninsured residents. 

“We have an all-payer model for health coverage that helps reduce the upward pressure on costs,” Levine said. “And as we all know, affordability leads to greater access to preventive and ongoing care, which leads to improved population and individual health outcomes.”

A collaborative process
Vermont takes what Levine calls a “health-in-all-policies” approach. 

“It’s a way of weaving health messaging and evidence-based practices throughout government,” he said. “So, for example, if we were to build a new highway, we would also look at how it could benefit public health.”

As both state health commissioner and a clinician, Levine was part of a working group that sought ways to integrate clinical and public health with community work. 

“We have state grants to form community collaboratives,” he said. “Having a network of community stakeholders accountable for promoting health brings more of us to the table to fix a problem.”

Examples of health programs that are working in Vermont include requiring schools to stock healthy options in vending machines, and public-private partnerships around the state that hold events to promote healthy lifestyle behaviors. 

The Vermont Department of Health is built around local health offices. They have boots-on-the-ground staff who provide disease prevention and health promotion services in the community, from WIC to immunization. In particular, Vermont’s 3-4-50 campaign is a comprehensive effort that addresses the three behaviors — tobacco use, physical inactivity and poor diet — that to lead to the four diseases — cancer, heart disease, Type 2 diabetes and lung disease — that result in 50% of all deaths in the state. 

The department also produces health impact assessments. The detailed reviews of topics, such as a school district’s proposed transportation policy and a development plan for the state’s largest city, bring the health-in-all-policies lens to the city, town and neighborhood levels. 

“Not only are these impact assessments useful tools for planners, they help raise awareness of the many things we can all do to bend the curve toward improved population health and wellness,” Levine said.

Efforts like 3-4-50 and community-focused programming may help explain why Vermont ranks fourth among states for the percentage of adults who get regular physical activity, and fourth overall for all behavior measures in the “2019 America’s Health Rankings Annual Report.” 

Constructive feedback
The final ingredient for Vermont’s health success is its willingness to take action to improve. 

“We look at a measure and ask, ‘Why aren’t we doing better?’” Levine said. “When America’s Health Rankings are released, right after we check out the good stuff, we look very closely at where we are lacking, and discuss how our programs can be improved. We have a statewide focus on total quality management, so we are always looking to get better. We’re never satisfied!”

The desire for constant improvement is perhaps the biggest reason why Vermont rose from 20th in the first America’s Health Rankings back in 1990, to first overall in 2019 – the fifth time the state has attained the top ranking. 
What does Levine believe Vermont needs to improve? He cites reducing youth substance abuse, reducing youth obesity and increasing access to care via telehealth as three areas of focus.

“We created a new council to figure out a strategy to deal with substance use among youth, including a focus on afterschool programming,” he said. “And we have not yet done enough in telehealth – except for telepsychiatry.”
Vermont is working hard to improve health disparities.

“Even in a state that’s doing well overall, when you drill down there are dramatic disparities,” Levine said. “To address this, we have placed a high priority on social determinants of health and have made health equity a cornerstone of our State Health Improvement Plan and our State Health Assessment.

“We’re looking at equity issues, such as racism and discrimination, which are never comfortable topics, but it’s critical to pay attention and show how they contribute to disparities. To successfully address inequity, we must examine the structures and systems underlying the disparities.” 

Vermont’s standing in the “2019 America’s Health Rankings Annual Report” is a result of leaders always looking for best practices to emulate. 

“Each of our states have strengths and areas in which we can improve,” Levine said “Looking inward has been key to Vermont’s improved effectiveness. A strong institutionalized ethic of performance improvement creates a spirit of accountability. This, in turn, fosters a process of continually confronting our data and using it to strategize in an opportunistic way. 

“America’s Health Rankings make an important contribution to this by quantifying state efforts as a resource for our performance improvement.”

Check out America’s Health Rankings to learn more about Vermont’s work, and see how your state fares.