New study links America’s health to social, economic and environmental factors in state comparisons

New study links America’s health to social, economic and environmental factors in state comparisons

The state you live in could reveal a lot about your health. In the Health of the States project, researchers at Virginia Commonwealth University’s Center on Society and Health and the Urban Institute compared states on dozens of health-related measures. The first-of-its-kind study measured factors including life expectancy, heart disease prevalence and quality of life at an unprecedented level of detail.

The “HOTS Summary Report,” released Oct. 26, shows how states rank on 39 health outcomes. The report summarizes where states are doing well and where they need improvement. It also uncovers what may be driving the health outcome trends.

Beyond comparing state outcomes, the report also offers detailed information on 123 potential health drivers. These drivers span five domains — health care, health behaviors, social and economic factors, the physical and social environment, and public policies and spending. It also includes measures such as tobacco use and physical activity, traffic fatalities, racial segregation, walkability and social support for children.

“The Health of the States project and accompanying reports provide a more comprehensive picture of health in every state than any other resource to date,” said Steven H. Woolf, M.D., professor at VCU School of Medicine and director of the VCU Center on Society and Health. Woolf was the principal investigator and lead author on the report. “Anyone who is interested in how the factors that shape a person’s health are connected has something to gain from this report,” he said.

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Funded by the Robert Wood Johnson Foundation, the HOTS project is distinct from other health scorecards in the number of health outcomes and determinants included. By assessing more than 100 health determinants, the study provides a nuanced profile of the links between health and potential drivers, such as school safety and neighborhoods, exposure to adverse childhood experiences, expanded Medicaid coverage and investments in transit and social programs.

The complex causal pathways linking the variables need to be studied further, but this initial look at the health profiles of states and the associations among the many health drivers reveal several interesting findings. For example:

  • California is generally healthy, but has low rankings for certain measures of child and adolescent health. Similarly, mountain states like Utah and Colorado are often in the top 10 states for health statistics, but dominate the bottom 10 for suicide rates. These states are high-ranking overall, but have one type of health ranking on which they score poorly.

  • States with healthier built environments (e.g., places for physical activity, public transportation) and populations with higher levels of education, employment and income also had dramatically better outcomes on multiple health measures.

  • States with lower obesity rates spent more per capita on mass transit, and states with higher cigarette taxes had lower smoking rates, longer life expectancy and lower death rates.


Today’s release of the “HOTS Summary Report” and study methodology marks the first of several for the HOTS project. In the coming months, researchers will release a series of topic-specific supplements, offering more detail on the relationships discovered between categories of health outcomes and the 123 determinants examined. The Health of the States supplemental reports are as follows:

  • Spotlight on life expectancy and mortality
  • Spotlight on birth outcomes
  • Spotlight on child and adolescent health
  • Spotlight on sexually transmitted infections
  • Spotlight on injury fatalities
  • Spotlight on adult health status
  • Spotlight on overweight/obesity, diabetes and cardiovascular conditions
  • Spotlight on cancer, lower respiratory disease, influenza and pneumonia, and Alzheimer’s disease

“The HOTS data reveal new eye-opening patterns in health outcomes and health drivers across states,” said Laudan Aron, co-principal investigator and senior fellow at the Urban Institute. “These patterns suggest important causal pathways that researchers and others must now analyze with the goal of developing new policies and practices that can drive significant improvements in population health and well-being across the country.”

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