Staying Ahead of the Curve: Utah's Future Health Care Needs

Gardner Business Review January 2019 Applied economic analysis by the David Eccles School of Business

Rising health care expenditures, a growing senior Staying Ahead of the population, and a changing demographic profile will impact Curve: Utah’s Future Utah's future health care needs. Health Care Needs By: Laura Summers, Senior Health Care Analyst

INFORMED DECISIONSTM Kem C. Gardner Policy Institute and the David Eccles School of Business

Staying Ahead of the Curve: Utah’s Future Health Care Needs

ANALYSIS IN BRIEF At a Glance Utah is known as a low-cost, healthy state, but the factors that Prevalence of Utah Adults Age 65+ with Chronic Conditions, help us maintain our position as one of the healthiest states in the 2015 vs. 2065 country are changing. Rising health care expenditures, a growing Estimated number of adults age senior population, and a changing demographic profile will impact 65+with chronic conditions Utah's future health care needs. This report provides data and Chronic Conditions 2015 2065 information on Utah’s changing demographic profile and evolving Alzheimer’s* 29,000 112,174 demands for health care. Arthritis 153,552 593,951 Asthma 28,390 109,816 Key points include the following: Cancer (skin) 68,992 266,865 Cancer (all others) 50,370 194,835 n Utah’s health care expenditures are growing at one of Chronic Obstructive Pulmonary Disease 26,559 102,731 the fastest rates in the country. This increase is likely due Diabetes 63,802 246,791 Depressive Disorder 56,170 217,271 to the state’s rapid population growth, but could also reflect Heart Conditions 59,528 230,260 rising costs of health care and an increase in health care High Blood Pressure 172,174 665,981 utilization rates. Poor Oral Health** 80,592 311,736 n The percent of the population age 65 and older in Utah Total Population Age 65+ 305,273 1,180,818 Note: The estimated increase is solely a function of population growth and does not is expected to double over the next 50 years. An aging account for possible increases or decreases in the prevalence of chronic conditions population that is prone to a higher prevalence of chronic over time that could result from changes in the health or demographics of the state’s population, improvements in medical therapy, or the implementation of state or system- conditions will place upward pressure on individual, system, level policies and programs that promote healthy behaviors. Source: Kem C. Gardner Policy Institute analysis of Utah Behavioral Risk Factor Surveillance state, and federal-level health care spending and resources. System data, Office of Public Health Assessment, Utah Department of Health and Kem C. n Gardner Policy Institute 2015-2065 State and County Projections. Utah’s population is becoming more diverse and *Source: Kem C. Gardner Policy Institute analysis of data from the Alzheimer’s Association the state’s changing demographic profile may place Report, 2015 Alzheimer’s Disease Facts and Figures. **Source: 2016 prevalence data. Behavioral Risk Factor Surveillance System. new demands on Utah’s health care system. While different population groups have different health care Figure 3 Selected Age Groups as a Percent of Utah’s Total Population, needs, the severity of these needs vary based on individuals’ Selected Age Groups as a Percent of Utah’s Total Population, 2015 2065 2015–2065 genetics, behaviors, and socioeconomic status. 100% n Income levels differ considerably across Utah’s 10% 13% 15% 17% 19% 20% population groups and counties. Key economic indicators and health care outcomes show a clear urban-rural divide. 75% n 59% Utah ranked as the fifth healthiest state in 2018. This is an 59% 59% 57% 56% 56% improvement from eighth in 2016, but lower than the 1990s 50% when Utah consistently ranked first. n Increasing mental health needs, substance use disorders, 25%

Percent of Utah’s Population 31% as well as diverging access to health care are some of the 28% 26% 26% 25% 24% indicators negatively influencing Utah's ranking. 0% 2015 2025 2035 2045 2055 2065 To stay ahead of the curve, Utah decision makers should continue Median age: 30.7 Median age: 38.3 (U.S.: 37.8) (U.S.: 42.9)* to seek innovative health care policies and proactively develop 0-17 18-64 65+ new approaches to providing health care, improving the health of *2060 projection. Source: U.S. Census Bureau 2017 National Population Projection Tables. Source: Kem C. Gardner Policy Institute 2015-2065 State and County Projections. U.S. Utah residents, and lowering health care cost trends. median age from U.S. Census Bureau, Population Division Annual Estimates of the Resident Population for Selected Age Groups by Sex for the United States, States, Counties and Puerto Rico Commonwealth and Municipios: April 1, 2010 to July 1, 2017.

INFORMED DECISIONSTM 1 gardner.utah.edu Table of Contents

Introduction...... 3 Utah’s Spending on Health Care is Rising ...... 3 Increasing Insurance Costs...... 3 A Growing Percentage of High-Deductible Health Plans...... 4 Utah’s Demographics Are Changing...... 4 An Aging Population...... 4 Growing Diversity...... 6 Utah’s Position as the Healthiest State Has Slipped...... 12 Evolving Behavioral Health Care Needs...... 12 Diverging Access to Health Care ...... 13 Moving Forward ...... 14 References...... 16

INFORMED DECISIONSTM 2 gardner.utah.edu Staying Ahead of the Curve: Utah’s Future Health Care Needs Figure 2 2016 FigureAve r2age Annual Growth in Utah’s Family Income Compared to Health Insurance Costs, 2006 Introduction Average Annual Growth in Utah’s Family Income Compared Utah is known as a low-cost, healthy state. Thanks to our young to Health Insurance Costs, 2006‒2016 population and active lifestyles, we have the lowest per capita health care spending in the country and rank high on most Family Income 0.4% measures of healthy behaviors. That said, the factors that help us maintain our reputation as one of the healthiest states in the Family Plan country are changing. 3.9% tibles This report provides data and information on Utah’s changing edu c Individual Plan 6.4% demographic profile and evolving health care needs, highlighting D implications for Utah’s future health care system. Family Plan 2.4%

Utah’s Spending on emiums r Individual Plan 1.7% Health Care is Rising P 0% 1% 2% 3% 4% 5% 6% 7% Utah’s health care expenditures are growing at one of the fastest Note: Income is median family income. Premiums and deductibles represent average 1 rates in the country. This increase is likely due to the state’s rapid employee contributions and deductibles for private-sector employees enrolled in single and population growth, but could also reflect rising costs of health care family coverage. Inflation-adjusted (2016). Source: Kem C. Gardner Policy Institute analysis of Medical Expenditure Panel Survey data and an increase in health care utilization rates. From 1991 to 2014, and Census Bureau, Current Population Survey data. the fastest growing expenditures in Utah were in home health care and prescription drugs (including medical nondurable products). In terms of national health care spending, the Centers for Medicare Increasing Insurance Costs & Medicaid Services (CMS) projects that personal health care Just as the price of medical goods and services has increased, spending (which measures spending on medical goods and services so has the cost of insurance. Data from the Utah Insurance provided directly to patients) will grow at an average annual rate of Department show that Utah, like the rest of the country, 5.5‒5.7 percent from 2019 to 2026.2 Nationally, growth in the price experienced increases in the cost of health insurance coverage of medical goods and services contributes to close to half of this over the last decade.3 When adjusting for inflation, Utah’s median increase. Other primary contributors include increases in health family income was relatively stagnant between 2006 and 2016 care utilization, population growth, and changing demographics. with an average annual growth rate of 0.4 percent. However, the

Figure 1 Average Annual Percent Growth in Total Health Care Expenditures, 1991–2014

6% National Average

2% Average Annual Percent Growth Percent Annual Average 0% NV AK ID UT DE VT WY OR NC AZ NH TX SD MT WA SC NM CO ND VA NE FL MS MN ME GA KY WI OK AR IN TN MD MO WV CA MA IA HI OH NJ KS RI AL IL NY PA CT LA MI DC

Note: Health care expenditures includes spending for all privately and publicly funded personal health care services and products. Data does not indicate it is inflation-adjusted. Source: Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group. National Health Expenditure Data: Health Expenditures by State of Provider, June 2017.

INFORMED DECISIONSTM 3 gardner.utah.edu cost of health insurance premiums and deductibles for both family Figure 3 Figure 3 and individual health plans rose at an average annual rate more Selected Age Groups as a Percent of Utah’s Total Population, Selected Age Groups as a Percent of Utah’s Total Population, 2015 2065 than three times the rate of family income during this same period 2015–2065

(Figure 2). 100% 10% 13% 15% 17% A Growing Percentage of High-Deductible Health Plans 19% 20% 75% The purchase of health savings account (HSA)-qualified 59% high-deductible health plans has also significantly increased 59% 59% 57% 50% 56% 56% since the mid-2000s. These plans have lower monthly premiums, but the higher deductibles require individuals and fami- 25% lies to pay more in out-of-pocket costs before their insurance Percent of Utah’s Population 31% 28% 26% 26% 25% 24% plan begins to cover expenses. Today, HSA-qualified high-de- 0% ductible family health plans have a minimum deductible of 2015 2025 2035 2045 2055 2065 $2,700 with a maximum of $13,300 in out-of-pocket expenses.4 Median age: 30.7 Median age: 38.3 (U.S.: 37.8) 18-64 65+ (U.S.: 42.9)* This means that consumers enrolled in these plans are respon- 0-17 sible for paying $2,700 of their covered health care expenses (or *2060 projection. Source: U.S. Census Bureau 2017 National Population Projection Tables. more if the deductible is higher) before the insurance company Source: Kem C. Gardner Policy Institute 2015-2065 State and County Projections. U.S. median age from U.S. Census Bureau, Population Division Annual Estimates of the Resident Population begins to pay a portion of the costs. for Selected Age Groups by Sex for the United States, States, Counties and Puerto Rico Commonwealth and Municipios: April 1, 2010 to July 1, 2017. While high-deductible health plans may save individuals and families money in the short run through lower monthly premiums, they have been found to deter some individuals from seeking ap- High-deductible health plans currently comprise about 30 per- propriate medical care because of the higher, upfront out-of-pock- cent of Utah’s commercial health insurance market, compared et costs.5 Data from the National Health Interview Survey show that to only three percent in 2007. They make up 36 percent of Utah’s about one in ten adults report delaying or going without medical large group market (defined as employers with 51 or more em- care due to costs. This portion increases to one in four among unin- ployees), 31 percent of the state’s small group market, and 21 per- 9 sured adults.6 Data also show that four out of 10 adults would either cent of health plans purchased in the individual market. have to borrow money, sell personal items, or simply not be able to New federal rules provide greater access to short-term and other pay the cost if faced with a $400 unexpected expense. health plans exempt from Affordable Care Act provisions. While Unexpected medical procedures or emergencies often cost thou- these rules create more variety in the market, limited coverage sands of dollars, leaving people with high-deductible health plans options could potentially leave persons with high costs when vulnerable to the expense.7 A survey conducted in 2016 found faced with a medical emergency. that only 40 percent of individuals with high-deductible health plans saved for future health services.8

Utah’s Demographics Are Changing An Aging Population tions, which is a key driver of health care spending. For example, While population growth, growth in the use and intensity of health Utah data show that only 4.6 percent of adults under age 65 have 13 care services, and the rising price of medical goods and services diabetes, compared to 20.9 percent of adults age 65 and older. were the primary drivers of national health care spending from Many chronic conditions, such as diabetes, develop over time and may go undiagnosed until later in a person’s life when their effects 1991‒2014,10 Utah’s aging population could have more of an impact in the future. The percent of the population age 65 and older become more acute. in Utah is expected to double over the next 50 years, 11 which could A 2017 RAND study found that individuals with one-to-two chron- place upward pressure on individual, system, and state-level health ic conditions spend more than twice the amount of money on care spending and resources (Figure 3). health care services than those with no chronic conditions, while 14 People age 65 and older visit a physician more than twice the rate those with five or more chronic conditions spend 14 times more. Individuals with one-to-two chronic condition account for 23 per- of people age 18‒44 (7.5 visits per year v. three visits).12 This age group also tends to have a higher prevalence of chronic condi- cent of total health care spending, and those with five or more chronic conditions account for 41 percent.15

INFORMED DECISIONSTM 4 gardner.utah.edu Table 1 Table 2 Prevalence of Utah Adults Age 65+ with Chronic Conditions, Utah Counties impacted by an Aging Population, 2015 vs. 2065 2015–2065

Prevalence of Estimated number of Counties with the Counties with the Chronic chronic conditions adults age 65+with Greatest Increase in the Portion Fastest Growing Conditions for age 65+ chronic conditions of their Population Age 65+ Population Age 65+ 2015 2015 2065 Percentage Average Annual County Point Increase County Rate Increase Alzheimer’s* 9.5% 29,000 112,174 San Juan 17.3 Wasatch 3.9% Arthritis 50.3% 153,552 593,951 Grand 16.4 Tooele 3.6% Asthma 9.3% 28,390 109,816 Summit 16.4 Utah 3.5% Cancer (skin) 22.6% 68,992 266,865 Tooele 15.9 Juab 3.3% Cancer (all others) 16.5% 50,370 194,835 Source: Kem C. Gardner Policy Institute 2015-2065 State and County Projections. Chronic Obstructive 8.7% 26,559 102,731 Pulmonary Disease Diabetes 20.9% 63,802 246,791 upward pressure an aging population will place on individual, sys- Depressive Disorder 18.4% 56,170 217,271 tem, and state-level health care spending in Utah. Heart Conditions 19.5% 59,528 230,260 An aging population that is prone to a higher prevalence of High Blood Pressure 56.4% 172,174 665,981 chronic conditions will not only place greater stress on Medicare Poor Oral Health** 26.4% 80,592 311,736 and the federal budget, but the state’s budget as well. Based on Total Population Age 65+ 305,273 1,180,818 current population projections, more than one million people in Note: The chronic conditions with the fastest growing prevalence in adults age 65 and older Utah will be enrolled in Medicare in 2065 compared to roughly are diabetes and depression. Estimates are not mutually exclusive and include adults who have 16 ever been diagnosed with the condition. “Heart Conditions” includes adults who have ever 384,000 in 2018. suffered a stroke, from angina/coronary heart disease, and/or a heart attack. “Poor Oral Health” is adults aged 65+ who have lost six or more teeth due to tooth decay or gum disease. In terms of state spending, Utah currently has the lowest per cap- Source: Kem C. Gardner Policy Institute analysis of Utah Behavioral Risk Factor Surveillance ita Medicaid spending in the country, which is in part explained System data, Office of Public Health Assessment, Utah Department of Health and Kem C. Gardner Policy Institute 2015-2065 State and County Projections. by Utah’s low Medicaid enrollment rate as well as its low propor- *Source: Kem C. Gardner Policy Institute analysis of data from the Alzheimer’s Association tion of enrollees over age 65 or who have a disability.17 However, Report, 2015 Alzheimer’s Disease Facts and Figures. **Source: 2016 prevalence data. Behavioral Risk Factor Surveillance System. this level of spending could change as the state’s population ages. Medicaid, which is a federal program jointly administered and Table 1 shows the expected increase in the number of adults age funded by each state, is a major payer of long-term services and 65 and older with chronic conditions in 2065. The estimated in- supports for the senior population (e.g., nursing home care, home crease is solely a function of population growth and assumes that and community-based services, etc.). Long-term services and the percent of the population with each chronic condition remains supports is also the most expensive type of care for the state to 18 constant over the next 50 years. The analysis does not account for provide (Figure 4). Compounding this issue is the fact that there possible increases or decreases in the prevalence of chronic con- will be a smaller percentage of people in the workforce to support ditions over time that could result from changes in the health or the aging population as the demand for federal and state-funded demographics of the state’s population, improvements in medical health care services increases (Figure 3). therapy, or the implementation of state or system-level policies and Utah’s aging population could have a disproportionate effect programs that promote healthy behaviors. These statistics illustrate on health in the state’s rural areas as many of these counties the potential impact population growth will have on Utah’s health are already struggling with a growing shortage of physicians. care system as well as highlight the need to further understand the Figure 4 Research from the Utah Medical Education Council projects that Average Monthly Medicaid Expenditures per Recipient in Utah, State Fiscal Year 2017

Figure 4 $73 Average Monthly Medicaid Expenditures per Recipient in Utah, State Fiscal Year 2017 $283 $334

$5,770 $2,699 $446

Long-Term Services and Supports Hospital Care Managed Care (ACOs) Pharmacy Physician Services Other Services

Note: Costs are inflation-adjusted using the medical care CPI (Consumer Price Index) from the U.S. Bureau of Labor Statistics. Costs represent Medicaid fee-for-service expenditures. All ACO costs are reflected in the managed care category. Source: Division of Medicaid and Health Finance, Utah Department of Health.

INFORMED DECISIONSTM 5 gardner.utah.edu Figure 5

GrFigureowth 5 in Utah’s Minority Population, 1980 2017 Figure 6 Growth in Utah’s Minority Population, 1980–2017 Shares of Minority Growth by Race and Hispanic Origin in Utah, 2016-2017 30% 92.4% 100% 91.2% 85.3% 80.4% 78.5% 25% 80% NH Two or More Races 20% 14% 60% NH Native Hawaiian or 15% 14.0% 4% 13.0% 40% Paci c Islander 10% 9.0% 4.9% 20% NH Asian 15% 5% 4.1% 7.5% Hispanic

Minority share of population 5.7% 6.7% 3.4% 3.9% Majority share of population 0% 0% NH American Indian 58% 1980 1990 2000 2010 2017 or Alaska Native 2% 7% White Alone (Not Hispanic or Latino) NH Black Other Minority (Not Hispanic or L atino) Hispanic or Latino Origin (of any race) Note: NH = Non-Hispanic. Sources: U.S. Census Bureau Population Division 2017 Vintage Estimates; 2010 Decennial Source: Kem C. Gardner Policy Institute analysis of U.S. Census Bureau, Population Division, Census; 2000 Decennial Census; 1990 Decennial Census; 1980 Decennial Census. June 2018.

Utah’s health care systems will need to replace almost 19 rural population growth. Natural increase (annual births minus annual area physicians per year over the next decade to account for deaths) contributed the other 54 percent.26 19 physician retirement. Between 2016 and 2017, just over 40 percent of the state’s Utah’s rural areas also have high proportions of U.S. veterans. For population growth came from minority groups (defined as example, the counties with the highest percentage of U.S. veterans any race category that is not non-Hispanic white) and people include Kane County (11.4 percent), Piute County (11.3 percent), identifying as Hispanic or Latino.27 Over half of this growth (58 Garfield County (10 percent), and Tooele and Washington counties percent) was from the Hispanic or Latino population (Figure 6). (9.7 percent).20 At a county level, the percentage of populations comprised of Persons who served in the Gulf and Vietnam Wars now make up minority groups range from 4.9 percent in Morgan County to 28 the majority of veterans in all of Utah’s counties21—and today 56 percent in San Juan County. At a state level, most of Utah’s these veterans are roughly between the ages of 45 and 70. minority populations reside along the Wasatch Front (Figure 7). Individuals currently serving in the Iraq and Afghanistan wars will While different population groups have different health care be reaching retirement age in the next 50 years. Many of these needs, the severity of these needs vary based on individuals’ veterans return from combat experiencing posttraumatic stress genetics, behaviors, and socioeconomic status. National data show disorder, traumatic brain injuries, and pain.22 that low-income adults are almost five times as likely to report As Utah’s veterans age over the next several decades, it is having only fair or poor health, and more than three times as important to ensure that their physical and mental health care likely to have activity limitations due to severe chronic conditions, needs can be adequately addressed in both urban and rural areas. compared to adults with family incomes above 400 percent of the federal poverty level (roughly $100,000 for a family of four).29, 30 Growing Diversity The state of Utah has a relatively low poverty rate compared to Utah’s population is becoming more diverse and the state’s other states,31 but minority populations in Utah have significantly changing demographic profile may place new demands on higher poverty rates than non-minorities (Figure 9). Income levels Utah’s health care system as different population groups have also differ considerably by county and data show a clear urban- different health care needs, different approaches to food and rural divide on key economic indicators and health care outcomes. exercise based on their culture or religious affiliations, different Figure 10 shows the percent of households and families in each approaches to mental and behavioral health, and different access county with incomes less than $25,000. It also shows which 23, 24, 25 to the health care system. counties have rebounded from the recession and which counties In 2017, Utah’s net migration (people moving into the state minus have a higher percent of low-income households and families in people moving out of the state) was 11.2 percent higher than 2016 compared to 2010 (the height of the recession). in 2016 (26,989 v. 24,261) and comprised 46 percent of Utah’s

INFORMED DECISIONSTM 6 gardner.utah.edu Figure 7 Minority Share of Population by County, 2017 Share of Utah’s Total Minority Population by County, 2017

4.9% - 11.7% 0.0% - 1.7% Cache Cache 12.9% - 18.3% 3.0% - 3.8% 16.3% Rich 3.0% Rich Box Elder 8.4% 23.9% - 28.6% Box Elder 0.0% 8.4% - 16.0% 12.9% 1.0% 56.0% 48.7% Weber 23.9% Weber 9.0% State: 21.5% Utah Minority Population: 667,048 Davis Morgan Davis Morgan 4.9% 0.1% 16.1% Summit Daggett 6.7% 8.4% Summit Daggett 0.0% 15.2% 0.9% Salt Lake Salt Lake 28.6% 48.7% Tooele Tooele Wasatch Wasatch 16.8% Duchesne 1.7% Duchesne 16.6% 0.8% Utah 14.8% Uintah Utah 0.4% Uintah 17.6% 18.3% 16.0% 1.0%

Juab Juab 7.5% Carbon 0.1% Carbon 16.8% 0.5%

Sanpete Sanpete Millard 14.4% Millard Emery Grand 0.6% 17.4% 0.3% Emery Grand 9.0% 17.6% 0.1% 0.3% Sevier Sevier 8.2% 0.3% Beaver Piute Wayne Beaver Piute Wayne 15.3% 10.4% 9.3% 0.1% 0.0% 0.0%

Iron Gar eld Iron Gar eld 14.3% 11.7% 1.1% 0.1% San Juan San Juan 56.0% 1.3% Washington Kane Washington Kane 15.4% 8.9% 3.8% 0.1%

Source: U.S. Census Bureau Population Division 2017 Vintage Estimates.

Figure 8 FigureFair or 8 Poor General Health in Utah Adults by Income, 2016F iguFigurere 9 9 Fair or Poor General Health in Utah Adults by Income, 2016 PercPercentent of Uta of Utah’sh’s Popul Populationation in in P Povertyoverty byby RaceRa ce and and Ethnicity, 2016 Ethnicity, 2016 Percent of population Income 40%

27.7% <$25,000 31% 30% 26% 26% 23% 14.2% $25,000 - $49,999 20% 20% 17% 16%

10% 7.2% $50,000 - $74,999 10% 9%

0% 7.0% $75,000 + Asian alone alone White Two or Two race alone race more races more Hispanic or Some other (of any race) (of any Native alone Native Latino Origin Latino Islander alone Black or African American alone Native Hawaiian Native American Indian White alone, not alone, White and Other Paci c and Other Paci c and Native Alaskaand Native Hispanic or Latino

Note: Each rectangle represents three percent. Red indicates the percent of the adult Note: Poverty is defined as having poverty status anytime in the previous 12 months. Census population (age 18+) with fair of poor general health. Data is age-adjusted. Bureau uses a set of money income thresholds that vary by family size and composition to Source: Behavioral Risk Factor Surveillance System, Office of Public Health Assessment, Utah determine who is in poverty. Department of Health. Source: U.S. Census Bureau, 2012-2016 American Community Survey 5-Year Estimates.

INFORMED DECISIONSTM 7 gardner.utah.edu Figure 10 Table 3 Percent of Utah Households and Families with Yearly Birth Outcomes by County Income Less Than $25,000, 2016 Infant Mortality Rate Percent of live County per 1,000 Births, 2016 low-weight births, 2016 Increase in percent of Utah State of Utah 5.1 7 Cache households with income 21.4% less than $25,000 in 2010. Beaver 8.9* 8 Box Elder Rich Decrease in percent of Utah 15.7% 19.2% households with income Box Elder 5.2 7 Weber 17.5% less than $25,000 in 2010. Cache 4.6 6 Morgan State=16.4% Davis 11.6% 7.3% Summit Daggett 17.1% Carbon 2.9* 10 Salt Lake 10.4% Daggett NA NA 15.8% Tooele Wasatch Davis 4.7 7 12.7% 12.1% Duchesne Duchesne 5.1 7 Utah 19.3% Uintah 15.7% 16.8% Emery 6.6* 8

Juab Garfield NA 8 17.3% Carbon 26.3% Grand 4.5* 8 Iron 7.1 8 Sanpete Millard 21.3% Juab 5.4* 6 17.4% Emery Grand 19.0% 28.4% Kane 10.4* 8 Sevier 25.9% Millard 5.1* 7 Beaver Morgan 4.5* 7 Piute Wayne 21.9% 31.0% 22.6% Piute NA 11* Rich NA NA Iron Gar eld 28.1% 24.1% Salt Lake 5.0 7 San Juan 32.6% San Juan 5.9* 7 Washington Kane Sanpete 5.8 7 19.6% 25.4% Sevier 5.1* 9 Summit 4.6 9

Increase in percent of Utah Tooele 4.2 8 families with income Cache Uintah 4.4 8 14.5% less than $25,000 in 2010. Box Elder Rich 12.3% Decrease in percent of Utah Utah 5.0 6 10.8% families with income Weber 11.1% less than $25,000 in 2010. Wasatch 4.1 7 Morgan State=11.0% Davis 7.5% Washington 4.9 6 4.6% Summit Daggett 5.8% Wayne NA 10* Salt Lake 8.3% 10.4% Weber 6.4 8 Tooele Wasatch 7.3% 8.0% Duchesne *Has a relative standard error greater than 30% or is an unreliable estimate. Utah 13.2% Uintah Note: Infant mortality is the number of infants who died before they were one-year old 11.7% 11.6% (from 0 through 364 days of age). Seven-year average (2010-2016). Source: Office of Vital Records and Statistics, Utah Department of Health. Juab Note: Low-weight births are defined as when the infant weighs less than 2,500 grams 13.5% Carbon 15.6% (approximately 5 lbs., 8 oz.). Seven-year average (2010‒2016). Source: County Health Rankings & Roadmaps, The Robert Wood Johnson Foundation. Sanpete Millard 13.7% 10.1% Emery Grand 9.6% 20.2% Sevier Birth outcomes and life expectancy can be used to gauge the 15.5% Beaver overall health of a community. Table 3 shows the fetal mortality Piute Wayne 16.8% 22.9% 10% rate and percentage of low-weight births by county. In terms of life expectancy, Figure 11 visually presents the differences in Iron Gar eld 20.4% 15.2% health and wellbeing among Utah’s neighborhoods and shows San Juan 25.3% that there is a more than a 10-year difference in life expectancy Washington Kane between neighborhoods with the highest life expectancy (the 13.4% 9.7% Avenues and Foothill) and the shortest life expectancy (Glendale and South Salt Lake). This is despite there only being about a five Note: Red indicates counties that experienced an increase in the percent of population with income less than $25,000 since 2010 (2016 inflation-adjusted dollars compared to mile difference between these areas. 2010-inflation adjusted dollars). Grey indicates a decrease in percent of population with income less than $25,000 since 2010. Source: U.S. Census Bureau, 2012-2016 American Community Survey 5-Year Estimates.

INFORMED DECISIONSTM 8 gardner.utah.edu Figure 11 Life Expectancy at Birth by Utah Small Area, 2016

Rich & Cache Counties (except Logan) - 80.7

Box Elder County Ogden - Downtown (except Brigham City) - 80.5 74.8 Farmington/ Logan 81.8 Centerville Brigham City 83.1 75.4 Summit County SLC - 81.5 Glendale Foothill/ 74.4 UofU Avenues 84.5 84.1 Tooele County Daggett, Duchesne & South 77.8 Uintah Counties Salt Lake 77.5 73.2

Provo- Juab, Millard & North/ Sanpete Counties Carbon & BYU 79.1 Emery 82.7 Counties Grand 74.7 County 79.2

Sevier, Piute & Wayne Counties Red Bottom 4 areas with the shortest life expectancy 77.8 Green Top 4 areas with the longest life expectancy Cedar Beaver, Gar eld, City 73.2 to 76.0 (Shortest Life) 78.5 Kane & Iron Counties San Juan (except Cedar City) County 76.8 to 78.6 St George 77.3 79.1 79.1 to 81.2 81.4 Washington County N 81.3 to 84.5 (Longest Life) (except St George) - 81.0 County Boundary

Note: Life expectancy can be used to gauge the overall health of a community. Five-year average (2012-2016). Source: Center for Health Data and Informatics, Utah Department of Health.

Utah’s minority populations have shorter life expectancies with A study from the Centers for Disease Control and Prevention the exception of Asians and Hispanics (Figure 12). As a whole, (CDC) found that Hispanics have a higher life expectancy than Asians tend to be one of the healthiest population groups, which non-Hispanics due several factors, including lower self-reported contributes to the gap in life expectancy. One study found that smoking rates and lower death rates for a majority of the leading Asians tend to be older than whites for almost all causes of death. causes of death such as cancer, heart disease, and unintentional That said, statistics from the Utah Department of Health show injuries.33 However, substantial differences exist among Hispanics that the Asian population has higher rates of tuberculosis (Figure by origin, nativity, and sex—and as a population, Hispanics have 13) and gestational diabetes.32 higher death rates from diabetes, chronic liver disease/cirrhosis, and homicide. Hispanics also have a higher prevalence of obesity.

INFORMED DECISIONSTM 9 gardner.utah.edu Figure 12

Life Expectancy by Race and Ethnicity in Utah, 2016

86.2

81.1

ears 80.0 80.0

Y 79.8 80

78.8

ge in ge 77.9 A

75.7 75

70 American Asian Black Paci c White Hispanic Non- U.S. Indian Islander Hispanic

FigureFigure 12 12 Figure 13 Life Expectancy by Race and Ethnicity in Utah, 2016 TuberculosisTuberculosis Rat Rateses per 100,000 per 100,000 in Utah biny RUtahace and by E thniciRacet yand, 2017 Life Expectancy by Race and Ethnicity in Utah, 2016 Ethnicity, 2017

90 12

10.1 10.2 86.2

85 9 tion 7.2

81.1

a opul

ears 80.0 80.0

Y 79.8 80

78.8 6

ge in ge 77.9

P 100,000 per e 75.7 t

a 3.3 R 2.7 75 3

0.2 70 0 American Asian Black Paci c White Hispanic Non- U.S. American Asian Black Paci c White Hispanic Indian Islander Hispanic Indian Islander

Note: Life expectancy at birth by race and ethnicity was calculated using death counts over a Note: Rate is cases per 100,000 population. Five-year average (2013-2017). Data does not span of five years (2012-2016). indicate it is age-adjusted. Source: Center for Health Data and Informatics, Utah Department of Health. Source: Utah Behavioral Risk Factor Surveillance System. Tuberculosis Rates per 100,000 in Utah by Race and Ethnicity, 2017 Figure 14 While adolescent obesity rates vary by race and ethnicity (Figure AdolesFigurece n14t Obesity Prevalence by Race and Ethnicity in Utah, 2017 14), data shows that total adolescent obesity in Utah increased Adolescent Obesity and Overweight Prevalence by Race from12 5.4 percent in 1999 to 9.6 percent in 2017. Boys are more than and Ethnicity in Utah, 2017 twice as likely as girls to be obese (13.9 percent vs. 5.3 percent).34 29% 10.1 10.2 30% In terms of mental health, American Indians and Whites/Non-

Hispanics9 have the highest rates of depression and suicide among

Utah’s population groups (Figure 15). 22% tion 7.2

The data presented in this section represent only a small snapshot 20%

a opul 16% of Utah’s health and demographic picture. In order for Utah’s 15% health6 care system to continue to adapt to the state’s changing 14% 14%

demographics, it will be important to understand the evolving 11%

P 100,000 per e healtht care needs and challenges facing different individuals, 10%

a 3.3 8% R 7% population2.7 groups, neighborhoods, and counties—all in the 3 context of an aging population. Unmet health care needs not only impact a person’s health and wellbeing, but their ability to be a productive 0.2and producing 0% 0 memberAmerican of the economy as well. Paci cThe CDC estimates that Asian Black White Hispanic Black Asian White Indian Paci c Indian Islander White/ productivity losses due to employee absenteeism cost U.S. Islander Hispanic Hispanic American 35 (All Races) employers $225.8 billion per year. An aging workforce, chronic Non-White/ Non-Hispanic conditions, and mental health care issues such as stress, anxiety, Non-Hispanic Obese Overweight and depression additionally impact employers’ revenue.36 Note: Obesity data come from grades 8, 10, and 12. Overweight data come from grades 9, 10, If Utah’s changing physical and mental health care needs are and 12 (at or above the 85th percentile but below the 95th percentile for body mass index, by not adequately planned for, then Utah’s reputation as one of the age and sex). Given these data are based on self-reported height and weight, it is likely they under represent the prevalence of overweight or obesity among high school students. healthiest states may slip. Source: 2017 Prevention Needs Assessment. Utah Youth Behavioral Risk Factor Surveillance System.

INFORMED DECISIONSTM 10 gardner.utah.edu Details on Utah’s Foreign-Born Population Data from 2016 show that 33,036 foreign-born individuals have were from Asia and 36.4 percent were from Latin America.38 moved to Utah since 2010. About 20 percent of this population Utah has a higher percent of immigrants from Oceania and is enrolled in college or graduate school. Historically, 81,728 Northern America than the U.S. average and a lower percent of foreign-born individuals moved to Utah from 2000 to 2009.37 immigrants from Africa. The composition of this population has also changed over time. The Census Bureau’s definition of foreign-born population The proportion of people migrating from Asia has grown as a includes “naturalized U.S. citizens, lawful permanent residents share of Utah’s total foreign-born population, while the pro- (immigrants), temporary migrants (such as foreign students), portion migrating from Latin America has decreased (Figure A). humanitarian migrants (such as refugees and asylees), and TheseFigu numbersre A are consistent with national data, which show unauthorized migrants.”39 43.4Utah percent Fo rofeign the foreign-born Born Popul populationation, Re enteringcent Arri sincevals 2010 by Region of Birth, Entering After 2000 vs. 2010

Figure A Utah Foreign Born Population, Recent Arrivals by Region of Birth, Entering After 2000 vs. 2010

Entered the U.S. 2.2% between 2000-2011 7.4% 20.2% 4.6%2.7% 62.9%

Entered the U.S. 9.5% 44.5% 5.3% 3.1% 34.3% 3.3% after 2010

0% 25% 50% 75% 100% Europe Asia Africa Oceania Latin America Northern America

Note: Data for the population entering after 2000 come from the 2007‒2011 American Community Survey. Data for the population entering in 2010 or later come from the 2012‒2016 American Community Survey. Sources: U.S. Census Bureau (2000) and American Community Survey 5-Year Estimates; Kem C. Gardner Policy Institute Calculations.

Figure 15 FigureUtah 15 Mental Health Indicators by Race and Ethnicity, 2016 Utah Mental Health Indicators by Race and Ethnicity, 2016

23.9 24 23.2 21.9 21.9 21.6 20.8 19.9

18 16.9 16.7

13.5 12 11.1 11.2 10.1 9.7 8.8 8.5

0 American Indian Asian Black Paci c Islander White Hispanic Non-Hispanic U.S.

Depression (percent) Suicide (rate per 100,000)

Note: Depression is percentage of adults age 18 and older who have ever been told by a doctor, nurse, or other health professional that they have a depressive disorder, including depression, major depression, dysthymia, or minor depression. Reflects lifetime diagnosis and not current major depression. The suicide rate is the number of resident deaths resulting from the intentional use of force against oneself per 100,000 population. Two-year average (2014-2016). U.S. is 2016 data. All data is age-adjusted. *Has a relative standard error greater than 30%. Source: Utah Behavioral Risk Factor Surveillance System.

INFORMED DECISIONSTM 11 gardner.utah.edu Utah’s Position as the Healthiest State Has Slipped Several indicators measure how Utah’s health compares to other In the Commonwealth’s 2018 Scorecard on State Health System states. According to America’s Health Rankings, Utah ranked as Performance, Utah ranked fifth.41 The state’s overall rank did not the fifth healthiest state in 2018.40 This is an improvement from change from the previous report; however, Utah ranked worse in the eighth in 2016, but lower than the 1990s when Utah consistently areas of “access and affordability” and “prevention and treatment.” ranked first. Measures that Utah ranks poorly on compared to Utah ranked better in the area of disparity, which evaluates the other states include: margin of difference in select measures by income level. • Low number of primary care physicians per 100,000 population Specific measures Utah ranks poorly on include: • High incidence of new cases of pertussis or whooping cough • High out-of-pocket medical spending and low child immunization rates • Adults without a usual source of care • High rate of deaths due to drug injury of any intent • Adults with mental illness who report an unmet need (unintentional, suicide, homicide, or undetermined)

Figure 16 FigurePerce 16nt of Kindergarteners with an Exemption from One or More Vaccines, 2016-17 School Year Percent of Kindergarteners with an Exemption from One or More Vaccines, 2016-17 School Year

6% 5.1% 5%

2% U.S. Median

0% MS WV AL LA IN NY CA DC KY DE RI VA MA TN AR MD IA KS NC TX NJ OK NE SC SD CT NM PA OH FL GA HI NH ND MI MT VT NV WA ME AZ UT WI ID OR AK

Note: Non-medical exemptions in Utah rose from 3.6% in 2009-2010 to 4.9% in 2016-2017. Medical exemptions have remained stable at 0.2%. Sample designs vary by state. Medical and non- medical exemptions may not be mutually exclusive and some children may have both exemptions. Utah allows for both religious and personal belief exemptions. Source: National Center for Immunization and Respiratory Diseases.

Figure 17 FigureUnint 17entional and Undetermined Opioid Deaths per 100,000Evolving Popul Behavioralation, Utah Health and Care U.S., Needs 1999t 2016 Unintentional and Undetermined Opioid Deaths per 100,000 Some of these indicators reflect Utah’s changing health Population, Utah and U.S., 1999–2016 care needs, specifically an increasing prevalence of mental 16 14.9 health needs and substance use disorders. Utah experiences 12.8 depression and suicide at higher rates than the national tion 12 average (Figure 15) and has long experienced high rates of

opul a drug deaths (Figure 17 and Figure 18). Coupling this with a 8 shortage of mental health providers (particularly in rural areas),42 exacerbates the inability of individuals to get necessary care. 4 e per 100,000 P

t There is also a growing need to address the behavioral health a R of Utah’s children. The impacts of unmet behavioral health 0 needs are not only immediate (in 2015, suicide was the leading 43 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 cause of death for Utahns ages 10 to 17), but long-lasting as Utah U.S. well. Research from the Utah Department of Health shows that Adverse Childhood Experiences (ACEs), which include exposure Source: CDC National Center for Health Statistics. Data is age-adjusted.

INFORMED DECISIONSTM 12 gardner.utah.edu Figure 18 All Drug Overdose Deaths per 100,000 Population by Utah Small Area, 2015

Rich & Cache Counties (except Logan) - 12

Box Elder County Ogden - Downtown (except Brigham City) - 14.7 47.7 Logan 14.4 Brigham City 30.1 Summit County SLC - 14.6 Glendale 47.8

Tooele County Daggett, Duchesne & South 33.5 Uintah Counties Salt Lake 25.8 46.2

Juab, Millard & Sanpete Counties Carbon 21.4 & Emery Counties 52.8

Grand & Sevier, Piute & Wayne Counties San Juan 12.6 Counties Red Top 4 areas with the highest rates 10.4 of drug overdose and poisoning Cedar 9.7 - 17.7 City Beaver, Gar eld, 18.8 Kane & Iron Counties 18.8 - 26.8 (except Cedar City) 27.6 - 37.1 St George 27.6 46.2 - 52.8 25.5 Washington County (except St George) - 21 N County Boundary

Note: Includes drug overdose and drug poisoning deaths. The rate for the state of Utah is 22.1. The rate for the U.S. is 14.9. Data is age-adjusted. Three-year average (2013‒2015). Source: Violence and Injury Prevention Program, Bureau of Health Promotion, Division of Disease Control and Prevention, Utah Department of Health.

to physical, sexual, or verbal abuse as well as exposure to mental Diverging Access to Health Care illness, substance abuse, divorce, incarceration, or witnessing Utah’s uninsured rate is relatively low compared to other states abuse, were statistically associated with developing obesity, fair or that have not expanded Medicaid.45 However, this low uninsured 44 poor health, smoking, binge drinking, and depression as adults. rate is not consistent throughout the state or for all population As Utah’s behavioral health needs continue to grow, more groups. Utah’s uninsured rates for persons under age 65 range restorative initiatives, like Operation Rio Grande, may be from a low of 6.5 percent in Morgan County to a high of 17 percent necessary to deal with the negative consequences of unmet in San Juan County (Figure 19).46 Utah’s Hispanic population also behavioral health issues until larger-scale preventive measures has the highest uninsured rate among racial/ethnic groups, can be implemented. with over 22 percent of the population being uninsured. This is compared to seven percent of Caucasians and 11 percent of African Americans who are uninsured.47

INFORMED DECISIONSTM 13 gardner.utah.edu Figure 19 their employers (60‒65 percent) and Utah has the highest rate Utah’s Uninsured Rates by County, 2016 of employer-sponsored insurance (ESI) in the country.49 That said, the availability of ESI may be greater in some counties than 6.5 - 8.1 others as larger employers are more likely to provide employees Cache 8.4 - 9.7 9.3 Rich with health insurance than small employers. A 2017 study by the Box Elder 10.2 10.2 - 11.6 8.4 11.9 - 13.9 U.S. Bureau of Labor Statistics found that slightly more than half Weber 9.6 14.7 - 17.1 of all establishments with fewer than 50 workers offered health Morgan State Rate: 9.7 insurance to at least one employee. Comparatively, 97 percent Davis 6.7 6.5 Daggett 9.7 Summit 20.5 of establishments with more than 500 workers offered health Salt Lake 50 10.9 insurance to at least one employee. Tooele Wasatch 8.1 Duchesne 9.5 Table 4 shows the number of private sector establishments by size Utah 13.7 Uintah in each county. Small businesses make up the majority of estab- 7.9 12.9 lishments in each county, but the data also show that some coun- Juab 10.2 Carbon ties simply lack access to large employers that are more likely to 9.4 provide health insurance (while some exceptions apply, employ-

Sanpete ers with 50 or more employees may receive a penalty for not offer- Millard 12.7 13.1 Emery Grand ing health insurance to their employees). The data also show the 8.7 13.9 Sevier percent of private sector employees vs. government employees 10.6 in each county. Beaver Piute Wayne 12 Research also shows that the percent of private sector workers 12.8 13.6 with access to ESI is heavily related to workers’ wages. Nationally,

Iron Gar eld only 22 percent of workers with an average wage in the lowest 11.9 14.7 San Juan 10 percent of wages had access to ESI, compared to 93 percent of 17.1 workers with an average wage in the highest 10 percent.51 The av- Washington Kane erage annual wage of private sector employees by county is also 11.6 8.6 presented in Table 4.

Note: Uninsured rate is for those age 65 and younger. Moving Forward Source: Kem C. Gardner Policy Institute analysis of Census Bureau Small Area Health Insurance Estimates 2016. Utah is a healthy state when compared to other states in the country; however, rising health care expenditures, a growing senior population, and a changing demographic profile will When specifically looking at persons with low income (below 138 impact Utah's future health care needs. To stay ahead of the percent of the federal poverty level, FPL), Summit County and curve, Utah decision makers should continue to seek innovative Wasatch County have the highest uninsured rates (30.5 percent health care policies and proactively develop new approaches to 48 and 27.8 percent respectively). Salt Lake County and Utah providing health care, improving the health of Utah residents, County have the largest total number of uninsured individuals and lowering health care cost trends. with income below 138 percent FPL. The variation in the uninsured rate by county may be partially explained by the availability of jobs that provide health insurance. The majority of Utahns receive health care coverage through

INFORMED DECISIONSTM 14 gardner.utah.edu Table 4 Utah Employment Statistics, 2016

Private Sector Percent of Total Employees Average Number of Establishments by Firm Size Annual Private Total Private Sector 1 to 9 10 to 49 50 to 99 100 to 499 500+ Government Establishments Sector Weekly employees employees employees employees employees County Wage State of Utah 57,248 16,287 2,192 1,555 222 77,504 83.9% 16.1% $871 Beaver 124 41 2 3 0 170 72.2% 27.8% $628 Box Elder 859 205 26 21 4 1,115 86.4% 13.6% $711 Cache 2,574 633 66 65 6 3,344 81.4% 18.6% $655 Carbon 358 111 17 7 0 493 76.3% 23.7% $785 Daggett * 18 3 1 0 0 22 50.0% NA $446 Davis 5,263 1,475 204 109 9 7,060 77.6% 22.4% $771 Duchesne 499 117 9 4 1 630 71.7% 28.3% $933 Emery 123 55 1 5 0 184 72.3% 27.7% $927 Garfield 144 22 2 3 0 171 78.3% 21.7% $512 Grand 323 125 8 3 0 459 82.6% 17.4% $564 Iron 1,054 262 14 19 0 1,349 77.1% 22.9% $576 Juab 150 44 6 4 0 204 78.1% 21.9% $712 Kane 201 40 6 2 1 250 79.0% 21.0% $567 Millard 193 51 11 2 0 257 77.5% 22.5% $794 Morgan 234 39 3 2 0 278 77.0% 23.0% $742 Piute * 27 1 0 0 0 28 46.7% NA $433 Rich 84 8 0 1 0 93 73.6% 26.4% $459 Salt Lake 22,480 7,115 1,114 780 109 31,598 85.5% 14.5% $987 San Juan 191 55 7 3 0 256 60.7% 39.3% $671 Sanpete 323 94 5 8 1 431 65.7% 34.3% $571 Sevier 364 136 8 12 0 520 80.9% 19.1% $646 Summit 1,854 432 44 26 7 2,363 89.5% 10.5% $801 Tooele 614 190 12 17 2 835 75.3% 24.7% $719 Uintah 810 214 12 10 0 1,046 75.6% 24.4% $835 Utah 9,754 2,490 319 256 33 12,852 87.1% 12.9% $840 Wasatch 759 138 12 10 0 919 81.9% 18.1% $704 Washington 3,705 925 105 57 3 4,795 86.8% 13.2% $649 Wayne 67 18 1 0 0 86 73.7% 26.3% $497 Weber 3,774 1,163 159 101 15 5,212 81.5% 18.5% $749

*State and local government employment numbers were not available. Note: County totals do not sum to state total given sampling error and non-sampling error estimates. Private sector establishment statistics exclude data from self-employed individuals (i.e., non-employers), employees of private households, railroad employees, agricultural production employees, and most government employees. Source: Kem C. Gardner Policy Institute analysis of U.S. Census Bureau 2016 County Business Patterns and Bureau of Labor Statistics Quarterly Census of Employment and Wages, 2016 Annual Averages.

INFORMED DECISIONSTM 15 gardner.utah.edu References

1. Centers for Medicare & Medicaid Services, Office of the Actuary, National 25. Cauce, A., Domenech-Rodriguez, M., Paradise, M, et al. (2002). Cultural and Health Statistics Group. National Health Expenditure Data: Health Contextual Influences in Mental Health Help Seeking: A Focus on Ethnic Expenditures by State of Provider, June 2017. Minority Youth. Journal of Consulting and Clinical Psychology, 70(1): 44–55. 2. National Health Expenditure Projections, 2017-26. (2018, February 14). 26. Harris, E. (2017, November). State and County Population Estimates for Office of the Actuary, Centers for Medicare & Medicaid Services. Utah: 2017. Kem C. Gardner Policy Institute. 3. Hawley, J. (2018, January). 2017 Health Insurance Market Report, State of 27. U.S. Census Bureau Estimates for Age, Sex, Race and Hispanic Origin, 2017. Utah Insurance Department. (2018, June). Kem C. Gardner Policy Institute. 4. 2018 limits set by the Internal Revenue Service (IRS). 28. Ibid. 5. Dixon, A., Greene, J., & Hibbard, J. (2008). Do consumer-directed health 29. Braveman, P., Egerter, S. (2008). Overcoming Obstacles to Health: Report plans drive change in enrollees' health care behavior? Health Affairs, 27(4): from the Robert Wood Johnson Foundation to the Commission to Build a 1120-31. Healthier America. Princeton, NJ: Robert Wood Johnson Foundation. 6. 2016 data. Kaiser Family Foundation analysis of National Health Interview 30. Schiller, J. S., Lucas, J. W., Peregoy, J.A. (2012). Summary Health Statistics Survey. Cox, C., Sawyer, B. (2018, January 17). How Does Cost Affect Access for U.S. Adults: National Health Interview Survey, 2011. Vital and Health to Care? Preston-Kaiser Healthy System Tracker. Statistics 10(256): Table 21. 7. The Federal Reserve System (2018, June 19). Report on the Economic Well- 31. 2012-2016 American Community Survey 5-year Estimates. Being of U.S. Households in 2017 - May 2018. Washington D.C. 32. Percentage of Birth Records Indicating Gestational Diabetes by Race, Utah, 8. Kullgren, J.T., Cliff, E.Q., Krenz, C., et al. (2018). Consumer Behaviors Among 2015. Utah Birth Certificate Database, Office of Vital Records and Statistics, Individuals Enrolled in High-Deductible Health Plans in the United States. Utah Department of Health. JAMA Intern Med. 178(3): 424–426. 33. Dominguez, K. (2015, May 8). Vital Signs: Leading Causes of Death, 9. Hawley, J. (2018, January). 2017 Health Insurance Market Report, State of Prevalence of Diseases and Risk Factors, and Use of Health Services Among Utah Insurance Department. Hispanics in the United States — 2009–2013. Morbidity and Mortality 10. Cuckler, G., Sisko, A., et al. (2018). National Health Expenditure Projections, Weekly Report. CDC. 2017-26: Despite Uncertainty, Fundamentals Primarily Drive Spending 34. Utah Department of Health Office of Public Health Assessment. (2018). Growth. Health Affairs, 37(3): 482-492. Utah Health Improvement Plan 2018. Salt Lake City, UT: Utah Department of 11. Perlich, P., Hollingshaus, M., Harris R., Tennert, J., & Hogue, M. (2017, July). Health. Utah’s Long-Term Demographic and Economic Projections Summary. Kem 35. Worker Illness and Injury Costs U.S. Employers $225.8 Billion Annually. (2015 C. Gardner Policy Institute. January 28). CDC Foundation. 12. Utah Medical Education Council (2016). Utah’s Physician Workforce, 2016: 36. Ibid. A Study of the Supply and Distribution of Physicians in Utah. Salt Lake City, 37. 2012-2016 American Community Survey 5-year Estimates. UT. 38. Ibid. 13. 2015 data. Kem C. Gardner Policy Institute analysis of Utah Behavioral Risk 39. About Foreign-Born Population. (2016, July 6). United States Census Bureau. Factor Surveillance System data, Office of Public Health Assessment, Utah Retrieved from https://www.census.gov/topics/population/foreign-born/ Department of Health. about.html#par_textimage. 14. Buttorff, C., Ruder, T., Bauman, A. (2017). Multiple Chronic Conditions in the 40. America’s Health Rankings Annual Report, 2018 Edition. ©2018 United United States. RAND. Health Foundation. 15. Ibid. 41. Radley, D., McCarthy, D. & Hayes S. (2018, May) 2018 Scorecard on State 16. Centers for Medicare & Medicaid Services, Medicare Enrollment Dashboard, Health Performance. The Commonwealth Fund. September 2018. Retrieved from https://www.cms.gov/Research-Statistics- 42. Utah Medical Education Council (2016). Utah’s Mental Health Workforce, Data-and-Systems/Statistics-Trends-and-Reports/Dashboard/Medicare- 2016: A Study of the Supply and Distribution of Clinical Mental Health Enrollment/Enrollment%20Dashboard.html. Counselors, Social Workers, Marriage and Family Therapists, and 17. Brucker, S. (2018, May). Coverage and Costs: What’s Driving Medicaid Psychologists in Utah. Salt Lake City, UT. Spending in Utah? Utah Foundation. 43. Violence and Injury Prevention Program, Bureau of Health Promotion, 18. Complete Health Indicator Report of Medicaid Inflation, State of Utah Division of Disease Control and Prevention, Utah Department of Health. Environmental Public Health Tracking. (2017, December 20). Retrieved from Retrieved from https://ibis.health.utah.gov/indicator/complete_profile/ http://epht.health.utah.gov/epht-view/indicator/complete_profile/MedInfl. SuicDth.html. html. 44. Utah Health Status Update: Effects of Adverse Childhood Experiences. 19. Utah Medical Education Council (2016). Utah’s Physician Workforce, 2016: (2015, July). Utah Department of Health. A Study of the Supply and Distribution of Physicians in Utah. Salt Lake City, 45. Kem C. Gardner Policy Institute analysis of Census Bureau's March Current UT. Population Survey 2014-2017 data and 1-year American Community Survey 20. 2012-2016 American Community Survey 5-year Estimates. 2016 data. 21. Ibid. 46. 2016 Census Bureau Small Area Health Insurance Estimates. 22. Taylor, B., Hagel, B., Carlson, K. (2012 April). Prevalence and Costs of Co- 47. Ibid. occurring Traumatic Brain Injury With and Without Psychiatric Disturbance 48. Ibid. and Pain Among Afghanistan and Iraq War Veteran VA Users. Medical Care, 49. Kem C. Gardner Policy Institute analysis of Census Bureau's March Current 50(4): 342-346. Population Survey 2014-2017 data and 1-year American Community Survey 23. Why are some genetic conditions more common in particular ethnic 2016 data. groups? (2018, May 8) In Genetics Home Reference, Lister Hill National 50. Data from March 2016. Wile, D. (2017, June). Employer-sponsored Center for Biomedical Communications, U.S. National Library of Medicine, Healthcare Coverage Across Wage Groups. U.S. Bureau of Labor Statistics, National Institutes of Health, U.S. Department of Health & Human Service. Spotlight on Statistics. 24. Sobal, J. (2001). Social and Cultural Influences on Obesity. In P. Bjorntrop 51. Ibid. (Eds.) International Textbook of Obesity. Hoboken, NJ: John Wiley & Sons.; Banna, J. C., Gilliland, B., Keefe, M., & Zheng, D. (2016). Cross-cultural comparison of perspectives on healthy eating among Chinese and American undergraduate students. BMC Public Health, 16: 1015. Boyington, J. E. A., Carter-Edwards, L., Piehl, M., Hutson, J., Langdon, D., & McManus, S. (2008). Cultural Attitudes Toward Weight, Diet, and Physical Activity Among Overweight African American Girls. Preventing Chronic Disease, 5(2): A36.

INFORMED DECISIONSTM 16 gardner.utah.edu

Partners in the Kem C. Gardner Policy Institute Advisory Board Community Conveners Cameron Diehl Sterling Nielsen Ex Officio (invited) Lisa Eccles Cristina Ortega The following individuals Michael O. Leavitt Governor Gary Herbert Spencer P. Eccles Jason Perry and entities help support Mitt Romney Speaker Brad Wilson Matt Eyring Taylor Randall the research mission of the Senate President Board Kem C. Gardner Jill Remington Love Kem C. Gardner Policy Institute. Stuart Adams Scott Anderson, Co-Chair Christian Gardner Brad Rencher Representative Brian King Legacy Partners Gail Miller, Co-Chair Natalie Gochnour Josh Romney Senator Karen Mayne Clark Ivory Charles W. Sorenson The Gardner Company Doug Anderson Mayor of Salt Lake County Deborah Bayle Ron Jibson James Lee Sorenson Mayor Jackie Biskupski Intermountain Healthcare Cynthia A. Berg Mike S. Leavitt Vicki Varela Larry H. & Gail Miller Roger Boyer Kimberly Gardner Martin Ruth V. Watkins Family Foundation Wilford Clyde Derek Miller Ted Wilson Mountain America Credit Union Sophia M. DiCaro Ann Millner Mitt and Ann Romney Salt Lake City Corporation Kem C. Gardner Policy Institute Health Care Advisory Council Salt Lake County University of Utah Health Nathan Checketts Mikelle Moore Stephen L. Walston Edward Clark Phillip Singer Chad Westover Utah Governor’s Office of Joseph Miner Eric Hales Economic Development Zions Bank Kem C. Gardner Policy Institute Staff and Advisors Executive Partners Leadership Team Chris Redgrave, Zions Bank Mark and Karen Bouchard Natalie Gochnour, Associate Dean and Director Bud Scruggs, Cynosure Group The Boyer Company Jennifer Robinson, Associate Director Wesley Smith, Western Governors University Ivory Homes Shelley Kruger, Accounting and Finance Manager Staff Salt Lake Chamber Colleen Larson, Administrative Manager Samantha Ball, Research Associate Sorenson Impact Center Dianne Meppen, Director of Survey Research Pamela S. Perlich, Director of Demographic Research Mallory Bateman, Research Analyst WCF Insurance Juliette Tennert, Director of Economic and DJ Benway, Research Analyst Public Policy Research Marin Christensen, Research Associate Sustaining Partners Nicholas Thiriot, Communications Director Mike Christensen, Scholar-in-Residence Clyde Companies James A. Wood, Ivory-Boyer Senior Fellow John C. Downen, Senior Managing Economist Dejan Eskic, Senior Research Analyst Dominion Energy Faculty Advisors Emily Harris, Demographic Analyst Staker Parson Companies Matt Burbank, Faculty Advisor Michael T. Hogue, Senior Research Statistician Adam Meirowitz, Faculty Advisor Mike Hollingshaus, Demographer Thomas Holst, Senior Energy Analyst Senior Advisors Meredith King, Research Coordinator Jonathan Ball, Office of the Legislative Fiscal Analyst Jennifer Leaver, Research Analyst Gary Cornia, Marriott School of Business Angela J. Oh, Senior Managing Economist Theresa Foxley, EDCUtah Levi Pace, Senior Research Economist Dan Griffiths, Tanner LLC Joshua Spolsdoff, Research Economist Roger Hendrix, Hendrix Consulting Paul Springer, Senior Graphic Designer Joel Kotkin, Chapman University Laura Summers, Senior Health Care Analyst Darin Mellott, CBRE Natalie Young, Research Analyst

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