Health in Kansas is Falling Behind – What Can Be Done

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Health in Kansas is Falling Behind - What Can Be Done?

Kansas was once one of the healthiest states in the nation. However, the past three decades have seen a significant decline in our state's health status compared to the rest of the country. In 1991, Kansas was ranked as the eighth healthiest state in the nation by America's Health Rankings. Fast forward to today, and our rank has slipped to 29th. In 2019, the United Health Foundation stated that Kansas experienced the steepest decline in America's Health Rankings among all states. Moreover, the gap in age adjusted all-cause mortality rates between Kansas and the national average has shifted since 1999. At that point, the age adjusted all-cause mortality rate in Kansas was 27.5 deaths per 100,000 fewer than the U.S. By 2020, however, Kansas' rate exceeded the U.S. by 46.8 deaths per 100,000. This represents a widening of approximately 75 deaths per 100,000 people from 1999 to 2020. The increasing trend in this gap is remarkably consistent, suggesting that this isn't an anomaly.

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Data from the Centers for Disease Control and Prevention reveal that both Kansas and the U.S. experienced declines in age adjusted all-cause mortality rates from 1999 to 2019, with a notable spike in 2020 due to the pandemic. Kansas boasted lower age adjusted all-cause mortality rates than the national average until 2005, signifying a healthier population. However, trends shifted as age adjusted all-cause mortality rates across the U.S. began to improve more sharply than in Kansas. This discrepancy became especially evident from 2009 to 2019, a period during which the U.S. saw continued improvements, but Kansas plateaued (Figure 1).

These trends signal an escalating health challenge in Kansas, posing a threat to the state's overall well-being and its competitive standing with other states. Although it might seem contradictory, given that overall health status in Kansas has seen improvements, it's critical to acknowledge that these gains aren't as great as would have been expected and that health standards change over time.

Note: The gap between Kansas and the U.S. favored Kansas by 27.5 deaths per 100,000 in 1999 and favored the U.S. by 46.8 deaths per 100,000 in 2020.

Source: KHI analysis of data from the Centers for Disease Control and Prevention, National Center for Health Statistics. (2024). CDC WONDER Online Database. Retrieved from https://wonder.cdc.gov/.

Why Might Health in Kansas be Losing Ground?

Before pinpointing specific health conditions or behaviors where Kansas falls short, it's crucial to consider the broader context that shapes population and individual health. Health encompasses not only the absence of illness but also physical, mental and social well-being. It's influenced by a complex interplay of factors, encapsulated in what public health experts call the socio-ecological framework (Figure 2). This idea can be visualized as a "stream of causation," where upstream factors like policy, culture and societal values shape socioeconomic status, community conditions, individual behaviors and health outcomes.

To address these health challenges effectively, it's essential to identify "upstream" leverage points within policies, environment and systems that can lead to widespread health improvements. Healthy policies have the power to transform living conditions, influencing what people are exposed to and how they behave. Public health science underscores the difficulty of changing behaviors without altering the surrounding community conditions, especially on a population level.

Source: Adapted from country deep dive on the well-being economy: Iceland. Copenhagen: WHO Regional Office for Europe; 2023. License: CC BY-NC-SA 3.0 IGO.

Strategic Opportunities for a Healthier Kansas

Edwards Deming, a pioneer in business process improvement, once observed that "every system is perfectly designed to get the results it gets." This suggests that the current public health structure in Kansas might be aligned with the outcomes we are experiencing. Reversing this trend is likely to take more than the traditional focus on specific diseases, risky behaviors or access to care. Getting below the surface, to how health is viewed in Kansas and our paradigm about what shapes it, may be needed. Outlined below are three examples of potential strategic opportunities to reshape the public health system and put us back on pace to be one of the healthiest states in the nation. Each of these examples emphasizes the need for a collaborative approach that engages various sectors in upstream solutions.

Explore Aligning the Public Health System Around the 10 Essential Public Health Services

The 10 Essential Public Health Services (Figure 3) are widely recognized as the gold standard in public health practice. This framework outlines the critical activities necessary to prevent disease, promote health and extend life across the population. It helps to clarify the roles of public health organizations, distinguishing them from health care and social services. The 10 Essential Public Health Services are intended to leverage the unique strengths of government and to create synergies with the private and nonprofit sectors. The 10 Essential Public Health Services provide a foundation for a more data-driven, evidence-based and community-engaged form of public health.

However, only seven of the 100 local health departments in Kansas have received PHAB accreditation - signifying a low alignment with the 10 Essential Public Health Services. Recognizing the varied capabilities across the state, there is an opportunity to explore how this framework might be more widely adapted to build an infrastructure to address the upstream social and structural determinants of health. Local health departments nearing readiness for accreditation could be provided incentives and support to help them over the tipping point, while health departments that are less ready could use resources like the Operational Definition of a Functional Local Health Department from the National Association of County and City Health Officials as a starting point.

Source: Centers for Disease Control and Prevention, 10 Essential Public Health Services, https://www.cdc.gov/publichealthgateway/publichealthservices/essentialhealthservices.html.

Build Public Health Capacity and Economies of Scale

Kansas ranks near the bottom in per capita public health funding, sitting third from the bottom. In 2020, Kansas allocated just $15 per person toward its public health system. This amount falls $20 short per person compared to Utah, which represents the national median for public health funding, and is lower than Georgia by $13, Nebraska by $26, Alabama by $32, Tennessee by $40, Colorado by $40 and Oklahoma by $41 - all of which are in the lower half of overall per-capita state spending. To regain its status as one of the healthiest states, it may be necessary to increase public health funding. Raising public health funding in Kansas to the national average would more than double the state's investment in its public health infrastructure. This could transform the options available for how the public health system is structured and what it could accomplish for Kansas.

In lieu of increased funding, improvements in efficiency and capacity may be possible now. Research shows that public health capacity and performance is low in local health departments serving populations smaller than 25,000 to 50,000 people.¹ In Kansas, about 77 percent of counties fall below this 25,000-person threshold. Multi-county local health departments are an approach to build economies of scale that have been advanced since at least the 1940s.³ There are two multi-county health departments already in Kansas and there are about 200 across the nation.² It may be beneficial for public health leaders in Kansas to explore the potential advantages of building economies of scale through larger multi-county local health departments.

Foster a Statewide Collaborative Infrastructure for Health in All Policies

Policy development is a core function of public health and the primary tool for addressing the social and structural drivers that shape health. Health in All Policies is a collaborative approach used to integrate health considerations into policy making across all the sectors that impact health. Yet many public health agencies lack the resources for effective policy work and only about a third of local health departments are implementing a Health in All Policies approach.² Health departments also face challenges advocating to the elected officials who also govern their organizations. Fostering a statewide collaborative infrastructure recognizes that public health policy development is a team sport.

By uniting various organizations and leaders committed to health in Kansas, we may be able to create a more robust policy infrastructure that could build synergy, create capacity and enhance the legitimacy of public health policy efforts. Using the collective impact framework, an organization like the Kansas Public Health Association, which represents a broad range of health professionals across the state, could serve as the backbone organization that brings together the shared goals and complimentary assets of the disciplines with a stake in the health of Kansas, such as public health, medicine, nursing, education, community-based organizations, business and various other sectors.

How KHI is Addressing this Challenge

KHI is actively engaged in comprehensive efforts to deepen our understanding of this challenge, pinpointing effective leverage points for change, and collaborating with state leaders to devise innovative solutions. This summer, we plan to dig into this issue by involving experts, leaders and communities from across Kansas. The aim is to explore and prioritize factors contributing to our current health trajectory. We consider this study a critical starting point for deconstructing the issue into more manageable elements, enabling more targeted and informed action. Potential subsequent initiatives may include conducting an epidemiological analysis to quantify the impact of various factors on our health decline, conducting qualitative research to illuminate and amplify the lived experiences of communities impacted by these health challenges and organizing meetings with national public health experts to examine and envision new directions for our public health infrastructure.

Conclusion

Over the past two decades, health in Kansas has not kept pace with the U.S. Reversing this trend will require meaningful changes to the systems that shape the social and structural drivers of health. Three potential strategic opportunities include aligning the public health system around the 10 essential public health services, building public health capacity and economies of scale and fostering a statewide collaborative infrastructure for Health in All Policies. However, it is essential that we identify more strategic opportunities for a healthier Kansas through dialogue, collaboration and innovative thinking. The journey toward a healthier Kansas will be challenging but is possible through collaboration and upstream action.

References

1. Erwin, P. C. (March 2008). The Performance of Local Health Departments: A Review of the Literature. Journal of Public Health Management and Practice 14(2): E9-E18, DOI: 10.1097/01.PHH.0000311903.34067.89
2. Cunningham, M., Patel, K., McCall, T., et al. (2024). 2022 National Profile of Local Health Departments. National Association of County and City Health Officials. Washington, DC. https://www.naccho.org/resources/lhd-research/national-profile-of-local-health-departments
3. Orthoefer, J., Daniel Bain, M., Raymond Empereur, M., & Toma Nesbit, M. A. (1988). Consortium Building Among Local Health Departments in Northwest Illinois. Public Health Reports, 103(5), 500-507.