The 2017 County Health Rankings for Colorado vividly show the relationship between health and money. The Colorado counties that scored best in the report tend to be the most affluent, while the ones that finished toward the bottom of the roster are typically poorer. But there are exceptions to this rule, as witnessed by Denver winding up near the back of the pack when it comes to the CHR’s two main metrics.
A program of the Robert Wood Johnson Foundation, the County Health Rankings analyze data for all fifty states, then ranks each county within them in terms of health outcomes and health factors.
Well-off Douglas County comes out on top in both areas in Colorado, with other top-ten finishers in each including Boulder County, Broomfield County, Routt County, Summit County and Pitkin County — all places with a high percentage of residents drawn to the areas for their active lifestyles.
On the other end of the scale, Costilla County, an area with more than its share of economic challenges, finishes last in each category among the 58 counties measured by the CHR staff.
And Denver County? It registers in 38th position for health outcomes and 43rd for health factors, in part because of the gap between the area’s haves and have-nots. But even the counties judged the healthiest aren’t immune to these disparities, many of which break down along financial and racial lines.
In the following Q&A, Kate Konkle, an associate researcher with the University of Wisconsin Population Health Institute, spells out the major issues that flow from the 2017 County Health Rankings, with specific references to plenty of Colorado counties. Then, on page two of this post, find the Colorado rankings. Click to read the Colorado report.
Westword: Is there a way to sum up Colorado’s performance in the County Health Rankings? Is it among the healthiest states overall? How does it compare to other states? Or do the variations from county to county make that kind of general statement impossible?
Kate Konkle: We really look at the health differences within states, not between them, to help people see that health is local and that where they live makes a difference in the opportunities they have to be healthy. Trust for America’s Health produces state health rankings that look at how states perform overall compared to each other.
The report has separate rankings for health outcomes and health factors. How would you describe the difference between the two? And how do they interact with each other?
Health outcomes are really a picture of today’s health (how long are people living, how healthy they feel). Heath factors are a picture of tomorrow’s health, and we look at a number of different things that impact and influence how healthy a community will be in the future. We know that if communities can improve health factors, they will over time all improve health outcomes.
Douglas County, a wealthy area located to the south and east of the Denver metro area, is ranked number one in both health outcomes and health factors. Why did it stand above the other counties in these categories? What are its major attributes?
For their health outcomes, Douglas has a very low premature-death rate and is among the top U.S. performers for this measure. This is a big factor in their high ranking for health outcomes. When we look at health factors, they do very well in social and economic factors, which is the biggest contributor to health and the overall rank for health factors. Only 3 percent of children live in poverty, 90 percent graduate from high school in four years, 87 percent have some college education (this is well above even the best-performers mark in the U.S.), and there is a low unemployment rate. These factors directly contribute to the good ranking and good health, and also play into some of the other areas, like low adult smoking rate and relatively good adult obesity rate.
However, even high-ranking counties have opportunities for improvement. The excessive drinking rate is a bit higher than we see on average in Colorado. A large number of people have a long commute and drive alone. And when we look a bit deeper into the children-in-poverty measure, we see that while only 3 percent of white children live in poverty, 7 percent of Hispanic children do and 12 percent of black children. So we always want to dig a bit deeper to understand if everyone within a county has the same opportunities, or if some populations maybe don’t have the same access and opportunities to good health.
Costilla County, located in southern Colorado along the New Mexico border, ranked 58th in both health outcomes and health factors. Why did it struggle in comparison with the other counties in Colorado? Also, what does NR stand for in the rankings — and why is it applied to six counties in Colorado?
Costilla County has a high premature death rate but also a very high low birthweight rate at 15 percent. You’ll also notice that almost one-quarter of adults report being in poor or fair health – that’s significantly higher than the Colorado average of 14 percent.
For health factors, if you really start with social and economic factors again, it’s a very different picture from Douglas County. Forty-three percent of children live in poverty, the unemployment rate is more than double that of Douglas County and only one-third of people have some college. They rate quite low on the food environment index, meaning they have little access to healthy foods (few grocery stores in a reasonable distance of residents) and higher levels of food insecurity. They do have a low rate of excessive drinking (a positive), and their adult obesity rate is right on par with the state average (another good thing for a lower-ranking county).
The NR means Not Ranked. Some counties in the nation are too small to have reliable measurements for health outcome measures. Those counties are not ranked.
Among the most highly ranked counties, there’s a mix of counties that stand out because of their affluence, and counties such as Ouray and Summit that tend to attract people who love outdoor activities. Do more affluent areas in general tend to score better in the County Health Rankings — not just in Colorado, but across the country? On the other hand, do counties that attract people with a strong love of outdoor activities sometimes trump more affluent counties thanks to the sort of people who choose to live there?
In general, given how much we know that social and economic factors impact health, wealthier counties do tend to perform better. Again, we know that things like education and income directly impact health and how long people live, but also factor into some of the other areas, like living in an area that has grocery stores that sell healthy foods and the ability to purchase healthy food, living in a safe community where you can play and walk outside, having health insurance and access to high-quality medical care. But opportunities to be healthy can also be access to great hiking trails and other outdoor activities, and, yes, they might attract those who value that lifestyle and in general live healthy lives. But I might suspect that some of those places have high levels of disparities — the haves and the have-nots when it comes to health and opportunity. For example, in a quick look at children in poverty broken down by race/ethnicity, 5 percent of white children live in poverty in Summit County and 44 percent of Hispanic children live in poverty. That’s a pretty alarming and striking difference.
Denver finishes 38th in terms of health outcomes and 43rd for health factors — positions that may strike many residents as surprisingly low. Why did Denver end up in these slots? What are the main reasons in each category that Denver scored poorly in relative terms? What are the main areas in which Denver needs to improve in order to become a healthier county?
Again, high rates of children living in poverty, lower high-school graduation rates, above-average severe housing problems, high teen birth rate and a very high STI rate all contribute to the lower health-factors ranking. And while they have had a higher-than-average premature-death rate compared to other Colorado counties (keeping in mind that Colorado is overall a pretty healthy state), the premature-death rate has been steadily dropping, and while it started well above both the U.S. and Colorado average fifteen years ago, it is now about the same as the U.S. average (looking at the trend graph will help you see this decline). So clearly, good things are already happening, and those efforts should be sustained and built on. And again, a focus on improving education and income will have the biggest impact on health in the long run, and on closing gaps among different populations that have different opportunities within the city/county.
Boulder and Broomfield counties score very well in both health outcomes and health factors. Do these counties represent something of a sweet spot, in that they’re relatively affluent and boast a culture that champions exercise and outdoor activities?
Very likely, yes.
Many rural counties in Colorado with relatively modest populations finish toward the bottom of the health outcomes and health factors rosters. Is this in part another indication that the lack of easily accessible health-care professionals and facilities can have a negative impact on the residents of such areas? In some ways, do these rankings send a message that these problems need to be addressed?
We do tend to see rural counties across the U.S., not just in Colorado, not performing as well. They tend to have higher rates of obesity, higher teen birth rates, high rates of injury deaths. We also know that many rural counties are challenged economically, with industries leaving and leaving behind higher unemployment rates. Many also may lack some of the infrastructure and opportunities that we know contribute to good health — health care being one of them, but also strong school systems, grocery stores in close proximity, and again, most important, jobs. We know that this isn’t true for every rural community, and some really do quite well, but it is a common trend in many.
Is there anything else about the study as a whole or Colorado’s rankings that I may have neglected to ask about that you feel is important to add?
I think the biggest thing to think about is that we provide communities with data so they can understand the health of their community and what contributes to it — not just to provide the information, but so that they can take action and change it. We also have, in addition to the data, tools and resources that communities can use to take action and bring partners together to determine the most important factors to address and local solutions that will result in positive change.
Michael Roberts has written for Westword since October 1990, serving stints as music editor and media columnist. He currently oversees Westword‘s news vertical.