Across the country and within every state, there are substantial shortfalls in the health of children based on their family's income and education, says a new report from the Robert Wood Johnson Foundation Commission to Build a Healthier America. The report is the first to rank states on infant mortality and children's health status based on key social factors, and it shows that as parent's income and levels of education rise, children's health improves.
 
The report, America's Health Starts With Healthy Children: How Do States Compare?, highlights the important role that income and education play in the health of America's children. It shows the unrealized health potential possible if all children had the same opportunities for health as those in the most well-off families. In almost every state and the District of Columbia, children in the poorest and least educated households suffer the worst health outcomes. But even middle-class children and children in well-off families are not as healthy as they could be.
 
"All parents want their children to grow up to lead long, healthy lives, but sadly, not all of our children have the same opportunities to reach those goals," says Commission Co-chair Alice M. Rivlin. "This report shows us just how much a child's health is shaped by the environment in which he or she lives. We seek to identify ways to narrow these gaps so our nation can put all children on an even path to good health."
 
Family Income and Children's Health
 
In the United States, 16 percent of children ages 17 and younger are in less than optimal health based on their parents' reports—a rate that varies widely across states from a high of 22.8 percent in Texas to a low of 6.9 percent in Vermont. But these rates also vary dramatically by income, both nationally and within states.
 
In Texas, for example, 44 percent of children in poor families are in less than optimal health compared with 6.7 percent of children in higher income families. Texas has the largest income gap in children's health status among all states.
 
The picture in New Hampshire is markedly different. Here, 13 percent of poor children are in less than optimal health compared with 6.4 percent of children in higher-income families. New Hampshire has the smallest income gap in children's general health status among all states.
 
In nearly every state, children in middle-income families also experience shortfalls in health compared with those in higher income families. And these differences in children's health by income can be seen across racial or ethnic groups, says the report by a research team based at the University of California at San Francisco's Center on Social Disparities in Health.
 
"Most of our efforts to improve health have focused on improving quality, access to and affordability of care. While these are important, support for better health that is associated with resources and community matters as well," says Commission Co-chair Mark McClellan. "As a nation, we clearly need to do better."
 
Infant Mortality and Mothers' Education
 
A mother's educational attainment is another social factor that can influence children's health. Nationally and in nearly every state, babies born to mothers with at least 16 years of education are less likely to die before their first birthdays than babies born to mothers who have not finished high school. In South Carolina, the infant mortality rate among babies born to mothers who are not high school graduates is 11.6 infant deaths per 1,000 live births, compared with 5.3 deaths per 1,000 births among babies born to mothers with at least 16 years of schooling. South Carolina has one of the largest gaps in infant mortality based on mother's education seen in any state.
 
But even among babies born to the most educated mothers, infant mortality rates in nearly every state exceed a rate that researchers say should be attainable in every state—a national benchmark rate of 3.2 infant deaths per 1,000 live births.
 
"There is substantial unrealized health potential among children in this country, both for the nation overall and within every state," says Susan Egerter, Ph.D., a lead study author. "Many health problems developed during childhood are linked to health problems that occur later in life. While access to medical care is clearly important, there is more to health than good medical care. Income and education matter," she adds.

The report shows how states compare on two key measures of children's health based on survey information and vital statistics and provides snapshots of how healthy children are and could be in each state. 
 
Additional highlights:
 
Children's Health and Income

• Four of every 10 children in the United States live in poor or near-poor households, and three in 10 live in middle-income households.
• Nationally and in nearly every state, children in poor families are more likely—more than six times as likely, in some states—to be in less than optimal health than children in higher-income families.
• With few exceptions, children in middle-income families also appear to be more likely—twice as likely, in some states—than wealthier children to be in less than optimal health.

Children's Health and Education

• One third of children live in households where no one has had schooling beyond high school; another third live with at least one person who has attended but not completed college. 
• While infant mortality rates are highest among babies born to mothers with no more than 12 years of schooling, the rate for babies born to mothers with 13 to 15 years of schooling is 40 percent higher than the rate for babies born to mothers with at least 16 years.
• Children in households without a high school graduate are more than four times as likely—and those in households with a high-school graduate, twice as likely—to be in less than optimal health as children living with someone who has completed some college.

Where are the gaps in children's health? 

• In Texas, the difference between the state's overall percent of children in less than optimal health and the percent in higher-income families was 16.1 percent, the largest income gap in children's general health status among all states.
• In contrast, in New Hampshire, there is a 2 percent difference between the overall percent of children in less than optimal health (8.3%) and the percent in higher-income families. This is the smallest income gap in children's general health status among all states. 
• The difference between the lower death rate for babies of the most educated South Carolina mothers and the current overall state rate of 8.5 deaths per 1,000 births, represents one of the largest gaps in infant mortality based on mother's education in the country. With an infant mortality gap of 3.2 percent, South Carolina ranks 46th in the size of its gap. 

How Do Your State and County Compare? The Education and Health Calculator
 
The release of the state-by-state report coincides with the launch today of a new online tool from the Commission that lets viewers see firsthand the links between education and mortality for states and most counties. The Education and Health Calculator is an interactive tool that lets users examine the current level of education in their own county or state and observe what might happen to death rates if a larger proportion of the population attended college. The user can determine the number of deaths per year that might be averted. The tool is available on the Commission's Web site http://www.commissiononhealth.org/calculator.

The Robert Wood Johnson Foundation Commission to Build a Healthier America is a national, independent nonpartisan group of leaders tasked with seeking ways to improve the health of all Americans. Launched in February 2008, the Commission is investigating how factors outside the health care system—such as income, education and environment—shape and affect opportunities to live healthy lives. The Commission, which is co-chaired by former senior administration officials Mark McClellan and Alice M. Rivlin, both now at the Brookings Institution, expects to issue a full set of recommendations in April 2009.