Health Disparities within States

The statewide measures used in America’s Health Rankings™ reflect the condition of the “average” resident.  However, when those measures are examined more closely, startling differences can exist within a state when race, sex, geographic location and/or economic status are considered.

The National Healthcare Disparities Report, released each year by the Agency for Healthcare Research and Quality, highlights disparities at a national level.  The report analyzes 22 core measures and indicates that disparities exist across many groups, including women, children, the elderly, rural residents, and among racial and socioeconomic groups.  The report also indicates that such disparities affect all aspects of health and health care delivery, including preventive care, acute care and chronic disease management, and affect many delivery locations including primary care, home health care, hospice, emergency care, hospitals and nursing homes.   

The National Healthcare Disparities Report finds that blacks receive poorer quality care than whites (73 percent of the 22 core measures are poorer for blacks), Hispanics receive poorer quality care than non-Hispanic whites (77 percent of the 22 core measures are poorer for Hispanics), and people living below the Federal poverty level receive poorer quality care than people earning 400 percent of the poverty level (71 percent of 22 core measures are worse for lower income people).  The disparities in the quality of care also worsening for blacks, Asians, Hispanics and the poor. [2]

While each state also has issues unique to their state that contribute to disparities, states that have been successful in reducing disparities in health indicators while retaining high overall health can serve as models for other states.

For example, Table 40 ranks the states based on years of potential life lost before age 75 for the most recent data year available, 2004.  This is a measure of premature death for a population.  Looking at the same measure, over a longer time span, speaks to what race discrimination may be present in each state.  Table 2 shows how these variations by race impact premature death rates in the United States, and Table 15 shows years of potential life lost by race for each state.

Table 2 - Premature Death (2002 - 2004)

The table above shows that the rate of premature death for blacks is almost 1.5 times higher than the rate for whites – a startling difference.  But white Americans also experience a substantially higher rate than Other Races (predominantly Asian, Pacific Islanders, & Native Americans).  The premature death rate for black or African Americans is fully 2.7 times that of the Other Race category.  These same disparities are also present in many of the states, as shown in Table 15.  The tables show that the ratio of the rate for black or African Americans ranges from less than 1.0 in Idaho, Wyoming, Vermont, Hawaii and New Hampshire to over 2.0 in Illinois and Wisconsin.  In 21 states, the ratio is 1.5 or higher – thus blacks have a 50 percent higher rate of potential life lost than whites in 21 of the states in the United States.  In those few states with a ratio below one, blacks fare as well as or slightly better than whites – so such disparities can be mitigated.

But Table 15 shows another startling difference between races if you look across states.  The highest rate of years of potential life lost occurs for Other Races in South Dakota, North Dakota, Wyoming and Montana.  In these four states, Other Races are predominantly Native Americans.  These rates are over 3.5 times the rate for Other Races in the remaining 46 states.

Disparities are also present in cancer incidence and cancer mortality.  Table 16 shows the age-adjusted incidence and mortality rates for all invasive cancers.  For whites, the incidence rate is 473.0 cases per 100,000 population, and for blacks, the incidence rate is 483.7 cases per 100,000 population, which is a relatively minor difference between the rates of incidence.  However, the mortality rate for whites is 191.2 deaths per 100,000 population, and for blacks, it is 239.6 deaths per 100,000 population, a 25 percent difference.    Table 16 shows that in 48 of the 50 states when comparing blacks to whites, the disparity in mortality rates is higher than the disparity in the incidence rate.  Thus, even though slightly more blacks may be getting cancer, many more blacks are dying from cancer when compared to whites.   

Table 17 shows the difference in years of potential life lost based upon degree of urbanization.[4] Disparity exists within states according to various levels of urbanization and between states for the same level of urbanization.  For example, in Maryland, the years of potential life lost in the central parts of large cities is over twice that in the fringe areas of these same cities.  A difference of over 4,000 years lost per 100,000 population between the center and fringe of large metro areas also exists in Michigan and Louisiana.  Also, within the same level of urbanization, large differences exist.  The years of life lost in non-urban areas of Louisiana and Mississippi is twice that of the non-urban areas in Massachusetts.  Similar disparities exist at all levels of urbanization.