The excise tax rate, in dollars per gallon, imposed by the state on beer containing 5% alcohol by volume. State beer excise tax does not include any additional taxes, such as those based on price rather than volume (e.g., ad valorem or sales taxes) that states have implemented at the wholesale or retail level.

How This Rating Was Determined
Data on state beer excise taxes were obtained from the Alcohol Policy Information System (12). As of January 1, 2014, state beer excise taxes ranged from $0.02 to $1.29 per gallon across states for which data were available. This rating reflects where the state’s tax fell within this range. For states with different tax rates for off-premises (e.g., liquor stores) and on-premises (e.g., restaurants) retailers, the off-premises tax rate was reported.

The excise tax rate, in dollars per gallon, imposed by the state on distilled spirits containing 40% alcohol by volume. State distilled spirits excise tax does not include any additional taxes, such as those based on price rather than volume (e.g., ad valorem or sales taxes) that states have implemented at the wholesale or retail level.

How This Rating Was Determined
Data on state distilled spirits excise taxes were obtained from the Alcohol Policy Information System (14). As of January 1, 2014, state distilled spirits excise taxes ranged from $1.50 to $14.25 per gallon across states for which data were available. This rating reflects where the state’s tax fell within this range. For states with different tax rates for off-premises (e.g., liquor stores) and on-premises (e.g., restaurants) retailers, the off-premises tax rate was reported.

The excise tax rate, in dollars per gallon, imposed by the state on wine containing 12% alcohol by volume. State wine excise tax does not include any additional taxes, such as those based on price rather than volume (e.g., ad valorem or sales taxes) that states have implemented at the wholesale or retail level.

How This Rating Was Determined
Data on state wine excise taxes were obtained from the Alcohol Policy Information System (15). As of January 1, 2014, state wine excise taxes ranged from $0.11 to $2.50 per gallon across states for which data were available. This rating reflects where the state’s tax fell within this range. For states with different tax rates for off-premises (e.g., liquor stores) and on-premises (e.g., restaurants) retailers, the off-premises tax rate was reported.

Laws that permit alcohol retail establishments to be held liable for injuries or harms caused by illegal service to intoxicated or underage customers.

How This Rating Was Determined
This rating reflects data provided by Alcohol Policy Consultations and ChangeLab Solutions on current state laws for commercial host liability (16–18). A state’s commercial host liability law was considered to have major limitations if it 1) covered underage patrons or intoxicated adults but not both, 2) required increased evidence for finding liability, 3) set limitations on damage awards, or 4) set restrictions on who may be sued.

The annual proportion of  E. coli O157 PFGE patterns reported to CDC (i.e., uploaded into PulseNet, the CDC-coordinated national molecular subtyping network for foodborne disease surveillance) within four working days of receiving the isolate in the state or local public health PFGE lab. PFGE is a technique used to distinguish between strains of organisms at the DNA level.

How This Rating Was Determined
The speed of PFGE testing for reported E. coli  O157 cases was determined by accessing the PulseNet national E. coli  O157 database for calendar year 2014. Turnaround times were calculated per lab by subtracting the received date (receipt in the PFGE lab) from the upload date (upload to the PulseNet national database), excluding weekends and federal holidays. The percentage of samples tested within four days was calculated by dividing the number tested within four days (numerator) by the total number uploaded to the PulseNet national database (denominator). If the received date for a sample was missing, the sample was counted in the denominator but not the numerator, thus lowering the percentage.

The rating reflects the extent to which the state tested E. coli  O157 cases within four days as determined by the PulseNet database.

The annual proportion of  Salmonella cases reported to CDC’s National Notifiable Diseases Surveillance System with PFGE patterns uploaded into PulseNet.

How This Rating Was Determined
The completeness of PFGE testing of reported Salmonella  cases was determined by accessing the PulseNet national Salmonella  database for calendar year 2014. The number of Salmonella  entries per state was determined and used as the numerator. The denominator was the number of cases reported by each lab to the National Notifiable Diseases Surveillance System for calendar year 2014.

The rating reflects the proportion of all Salmonella  cases tested in the state as determined by the PulseNet database.

Inclusion in the state’s food safety regulations of selected provisions contained in the 2013 FDA Food Code related to norovirus and other foodborne illnesses.

How This Rating Was Determined
Publicly accessible state food code regulations were assessed for the presence of the selected provisions contained in the 2013 FDA Food Code (10). The rating reflects the number of provisions included in state food safety regulations.

State health department implementation of activities to improve the state’s ability to prevent and control HAIs across four prevention areas: 1) building and maintaining partnerships (e.g., collaborating with quality improvement organizations or hospital associations), 2) supporting HAI-related outbreak response by building infrastructure to identify and respond to reports of outbreaks in healthcare settings, 3) conducting or supporting HAI training, and 4) validating HAI data (i.e., analyzing data for quality and completeness and/or reviewing medical records to check data accuracy).

How This Rating Was Determined
The rating reflects the number of HAI prevention areas the state has addressed. Ratings are based on data from a CDC 2015 survey of state HAI coordinators, which asked states whether their HAI prevention activities had addressed the following prevention areas: HAI partnerships, outbreak response, training, and data validation (12). Data validation responses were confirmed using the findings of the 2015 National and State Healthcare-Associated Infections Progress Report (13).

Programs in acute care hospitals that incorporate seven core elements CDC deems critical to successful hospital antibiotic stewardship: 1) leadership commitment, 2) accountability, 3) drug expertise, 4) actions to improve antibiotic use, 5) tracking antibiotic use and outcomes, 6) reporting antibiotic use and outcomes to staff, and 7) education (4).

How This Rating Was Determined
The rating reflects the percentage of the state’s acute care hospitals participating in the Patient Safety Component of NHSN that reported having antibiotic stewardship programs that incorporated CDC’s seven core elements (4). Ratings are based on data from the 2014 NHSN Annual Hospital Survey Patient Safety Component (9).

The percentage of office-based physicians demonstrating meaningful use of certified electronic health record (EHR) technology, as defined by the Centers for Medicare & Medicaid Services EHR Incentive Program’s meaningful use criteria (14).

How This Rating Was Determined
The rating reflects meaningful use of certified EHRs in the state as measured by the Centers for Medicare & Medicaid Services (23). Certified EHR technology must include clinical decision supports, such as alerts for elevated blood pressure and cholesterol levels based on laboratory results, to support guidelines-based clinical decision making (24).

A state legislative, regulatory, or other written administrative policy that authorizes qualified pharmacists working within the context of a collaborative practice agreement or defined protocol to perform patient assessments; order drug therapy-related laboratory tests; administer drugs; and/or select, initiate, monitor, continue, and adjust drug regimens (8–11).

How This Rating Was Determined
The rating reflects the status of the state’s CDTM policies as reviewed by CDC policy analysts (25). CDTM policies were rated on the extent to which pharmacists were able to enter into collaborative practice agreements that included all health conditions and all healthcare settings.

Medicaid (traditional state Medicaid programs and Medicaid expansion programs) reimbursement of healthcare providers for costs associated with routine HIV screening, regardless of the patient’s HIV infection risk. (In states with Medicaid expansion, persons insured under the expansion are covered for routine HIV screening as required by law [13], while enrollees in traditional state Medicaid programs might or might not be covered for routine HIV screening.)

How This Rating Was Determined

The rating reflects the extent to which the state’s Medicaid program supported routine HIV screening, as assessed by the Kaiser Family Foundation (KFF) and the National Alliance of State and Territorial AIDS Directors (NASTAD) (7,12,14).

Coverage of Routine HIV Screening—Traditional Medicaid: To assess coverage of routine HIV screening in traditional Medicaid fee-for-service programs, KFF surveyed state Medicaid officials in 2010 and 2013 (7). NASTAD updated the results in 2015 for all states without such coverage, except for two states (Alabama and Mississippi) that did not respond to requests for information (12).

Coverage of Routine HIV Screening—Medicaid Expansion Plans: Routine HIV screening is recommended with an “A” grade by the US Preventive Services Task Force and is covered without cost sharing in the “essential health benefits” package that Medicaid expansion plans provide to enrollees (9,15). Accordingly, all states that have expanded Medicaid coverage under the Affordable Care Act cover routine HIV screening for their expansion populations. State Medicaid expansion status was determined on the basis of data collected and posted by KFF as of April 29, 2015 (14).

Consistency of the state’s HIV testing law with key parameters of consent and counseling outlined in CDC’s 2006 HIV testing recommendations (8).

How This Rating Was Determined

The rating reflects the extent to which the state’s laws governing HIV testing met every consent and counseling parameter stated below.

CDC researches state laws, regulations, and policies that could influence risk behaviors or alter the environment in which HIV prevention services are accessed and delivered (17). To assess HIV testing laws, staff reviewed laws and regulations in the 50 states and the District of Columbia using WestlawNext© (an online legal research system), literature reviews, and web searches. Relevant laws and regulations were coded using the following parameters:

Consent parameters:

• Opt-out (rather than opt-in) testing
• Inclusion of HIV testing consent as part of general medical consent forms (rather than HIV-specific consent forms)
• Permission to give consent orally

Counseling parameter:

• No requirement for HIV prevention counseling prior to testing

Existence of a state statute, regulation, or policy that requires reporting of all CD4 and HIV viral load test results (detectable and undetectable); reporting of  ≥95% of CD4 and viral load results to the state or local health department; AND reporting by the health department of  ≥95% of laboratory results to CDC by the end of each year.

How This Rating Was Determined

The rating reflects the extent to which state CD4 and viral load reporting requirements were in place, as determined by a policy assessment conducted by CDC (10,11), and whether complete CD4 and viral load data were reported to CDC (1,10,11).

CDC researches state laws, regulations, and policies that could influence risk behavior or alter the environment in which HIV prevention services are accessed and delivered (17). To assess CD4 and viral load reporting requirements, staff reviewed laws, regulations, and directives in the 50 states and the District of Columbia using WestlawNext© (an online legal research system), literature reviews, and web searches. Relevant laws, regulations, and directives were coded using the following parameters:

• CD4 reporting: Required laboratories to report all values (not just those below a specified threshold)
• HIV viral load: Required laboratories to report all results (detectable and undetectable)

States were assessed as having complete reporting of laboratory results to CDC if, in addition to having state laws requiring the reporting of all levels of CD4 and viral load, the following criteria were met: 1) laboratories that perform HIV-related testing had reported a minimum of 95% of HIV-related test results to the state or local health department, and 2) by December 2014, the state had reported to CDC at least 95% of all CD4 and viral load test results received during January 2012–September 2014 (1).

Statewide percentage of viral suppression among persons with diagnosed HIV infection. A person’s viral load is considered suppressed when the results of a viral load test show either that HIV is undetectable or there are fewer than 200 copies/mL of virus in the blood.

How This Rating Was Determined

The rating reflects whether a state had a viral suppression prevalence ≥80% among persons aged ≥13 years who had HIV infection diagnosed by the end of 2011 and were alive at the end of 2012 (1).

Ratings are reported only for those states that met the following criteria: 1) the state’s law or regulations required reporting of all CD4 and all viral load data to the state or local health department (11), 2) laboratories that perform HIV-related testing had reported a minimum of 95% of HIV-related test results to the state or local health department, and 3) by December 2014, the state had reported to CDC at least 95% of all CD4 and viral load test results received during January 2012–September 2014 (1). Geographic designations of viral suppression reflect where persons resided at HIV diagnosis.

A primary enforcement seat belt law allows police to stop a vehicle solely because a driver or passenger is not wearing a seat belt. A secondary enforcement seat belt law requires police to have another reason for stopping a vehicle before citing a driver or passenger for not buckling up. The most comprehensive policies are primary seat belt laws that cover all occupants, regardless of where they are sitting.

How This Rating Was Determined
The rating reflects the extent to which the state’s seat belt law allowed for primary enforcement and covered all seating positions. Ratings are based on data collected from the Insurance Institute for Highway Safety (IIHS) on July 1, 2015, and therefore reflect IIHS’s interpretation of each state’s policy at that time (28). The “as of” date referenced—July 1, 2015—is the date CDC assessed the policy. The date does not reflect when the law was enacted or became effective.

A law that requires child passengers to travel in appropriate child passenger restraints, such as car seats or booster seats, until adult seat belts fit them properly.

How This Rating Was Determined
The rating reflects the age through which the state required child passengers to travel in appropriate child passenger restraints. Ratings are based on data collected from the Insurance Institute for Highway Safety (IIHS) on July 1, 2015, and therefore reflect IIHS’s interpretation of each state’s policy at that time (28). The “as of” date referenced—July 1, 2015—is the date CDC assessed the policy. The date does not reflect when the law was enacted or became effective.

Age at which a young driver can first acquire a learner’s permit, which requires a novice driver to practice driving under the supervision of an adult.

How This Rating Was Determined
The rating reflects the age at which the state allowed drivers to first acquire a learner’s permit. Ratings are based on data collected from the Insurance Institute for Highway Safety (IIHS) on July 1, 2015, and therefore reflect IIHS’s interpretation of each state’s policy at that time (29). The “as of” date referenced—July 1, 2015—is the date CDC assessed the policy. The date does not reflect when the law was enacted or became effective.

The length of time a driver must maintain a learner’s permit before being allowed to apply for an intermediate or provisional license.

How This Rating Was Determined
The rating reflects the length of time the state required a driver to maintain a learner’s permit before being allowed to apply for an intermediate or provisional license. Ratings are based on data collected from the Insurance Institute for Highway Safety (IIHS) on July 1, 2015, and therefore reflect IIHS’s interpretation of each state’s policy at that time (29). The “as of” date referenced—July 1, 2015—is the date CDC assessed the policy. The date does not reflect when the law was enacted or became effective. If a state had varying holding periods dependent on the age the young driver received his/her learner’s permit, the rating was based on the shortest holding period allowable for novice drivers. Exceptions to learner’s permit holding periods (e.g., a shorter holding period for completion of a driver’s education course) were not considered, and states were rated based on the general law.

A restriction against intermediate or provisional license holders driving without adult supervision during certain nighttime hours.

How This Rating Was Determined
The rating reflects the extent to which the state restricted intermediate or provisional license holders from driving without adult supervision at night. Ratings are based on data collected from the Insurance Institute for Highway Safety (IIHS) on July 1, 2015, and therefore reflect IIHS’s interpretation of each state’s policy at that time (29). The “as of” date referenced—July 1, 2015—is the date CDC assessed the policy. The date does not reflect when the law was enacted or became effective. If a state had varying nighttime driving restrictions dependent on the month of the year or day of the week, the rating was based on the least restrictive requirement. Provisions loosening restrictions based on the length of time the young driver had been licensed were not considered; states were rated based on the initial restriction only.

A restriction against intermediate or provisional license holders transporting more than a certain number of young passengers without adult supervision.

How This Rating Was Determined
The rating reflects the extent to which the state restricted intermediate or provisional license holders from transporting young passengers without adult supervision. Ratings are based on data collected from the Insurance Institute for Highway Safety (IIHS) on July 1, 2015, and therefore reflect IIHS’s interpretation of each state’s policy at that time (29). The “as of” date referenced—July 1, 2015—is the date CDC assessed the policy. The date does not reflect when the law was enacted or became effective. If a state had varying young passenger restrictions dependent on the time of day, the rating was based on the least restrictive requirement. Provisions loosening restrictions based on the length of time the young driver had been licensed were not considered; states were rated based on the initial restriction only.

The minimum age at which drivers, who have met all requirements of intermediate or provisional license, may first drive unsupervised without nighttime or young passenger restrictions.

How This Rating Was Determined
The rating reflects the minimum age at which the state allowed drivers, who have met all requirements of intermediate or provisional license, to first drive unsupervised with no nighttime driving or young passenger restrictions. States that did not have both restrictions were rated red. Ratings are based on data collected from the Insurance Institute for Highway Safety (IIHS) on July 1, 2015, and therefore reflect IIHS’s interpretation of each state’s policy at that time (29). The “as of” date referenced—July 1, 2015—is the date CDC assessed the policy. The date does not reflect when the law was enacted or became effective.

A law that mandates the use of ignition interlocks for drivers convicted of alcohol-impaired driving. An ignition interlock is a device that analyzes a driver’s breath and prevents the vehicle from starting if alcohol is detected.

How This Rating Was Determined
The rating reflects the extent to which the state required use of ignition interlocks for drivers convicted of alcohol-impaired driving. Ratings are based on data collected from the Insurance Institute for Highway Safety (IIHS) on July 1, 2015, and therefore reflect IIHS’s interpretation of each state’s policy at that time (30). The “as of” date referenced—July 1, 2015—is the date CDC assessed the policy. The date does not reflect when the law was enacted or became effective.

Percentage of secondary schools (middle schools and high schools) in the state that did not allow students to purchase less nutritious foods and beverages from vending machines, school stores, canteens, and snack bars.

How This Rating Was Determined
The rating reflects the extent to which the state’s secondary schools limited the sale of less nutritious foods and beverages. For a school to be identified as not selling less nutritious foods and beverages, the school principal had to respond “no” to each of the following five items on the CDC School Health Profiles principal questionnaire when asked whether students can purchase that item: 1) chocolate candy; 2) other kinds of candy; 3) salty snacks that are not low in fat, such as regular potato chips; 4) cookies, crackers, cakes, pastries, or other baked goods that are not low in fat; and 5) soda pop or fruit drinks that are not 100% juice (19). Data were collected prior to implementation of the Smart Snacks in School regulation and do not reflect impact of the regulation on school nutrition standards.

A state nutrition standards policy for sale of foods and beverages that meets the following criteria: 1) provides or references quantifiable nutrition standards (e.g., sets a maximum for the amount of sodium a food item can include) addressing four or more of the following nine foods or nutrients: fruits, vegetables, whole grains, water, added sugars, sodium, trans fat, saturated fat, and calories/portion sizes; 2) applies to all property and facilities owned, leased, or operated by the state executive branch; and 3) applies to two or more food service venues (e.g., vending machines, cafeterias, snack bars).

How This Rating Was Determined

The rating reflects whether the state had a nutrition standards policy for sale of foods and beverages and the extent to which the policy meets the following three criteria: 1) provides or references quantifiable nutrition standards (1,22), 2) applies to all state executive branch property, and 3) applies to two or more food service venues.

A policy was defined as a regulation, statute, or executive order. Policies were identified by searching WestlawNext^© (an online legal research system) for statutes and regulations and LexisNexis^® (an online database) for executive orders. Ratings indicate the presence of a policy, not whether it was implemented. For the purposes of this report, correctional facilities, schools, nursing homes, and personal care homes were excluded from the analyses.

Inclusion of some or all of the 47 components of national standards considered to have a high impact for obesity prevention into state licensing regulations of childcare facilities.

How This Rating Was Determined
The rating reflects the extent to which state licensing regulations for childcare facilities included the 47 recommended components of national standards considered to have a high impact for obesity prevention. Data were compiled from a report of the National Resource Center for Health and Safety in Child Care and Early Education (23). A state was considered to have included a component if its regulations for childcare centers, large family childcare homes, and small family childcare homes fully met the requirements of the component.

The average score for breastfeeding support in the state's participating birth facilities.

How This Rating Was Determined
The rating reflects the extent to which birth facilities (e.g., hospitals and birth centers) within the state implemented multiple evidence-based strategies that support breastfeeding. State average birth facility scores were obtained from CDC’s National Survey of Maternity Practices in Infant Nutrition and Care (mPINC) (25). Each birth facility that responded to a self-administered survey was scored on multiple evidence-based practices that support breastfeeding across seven categories: 1) labor and delivery, 2) breastfeeding assistance, 3) mother-newborn contact, 4) newborn feeding practices, 5) breastfeeding support after discharge, 6) nurse/birth attendant breastfeeding training and education, and 7) structural and organizational factors related to breastfeeding. The total score can range from 0 to 100, with a higher score representing more support. The national average score across all states was 75.

State-required interval between dispensing a controlled substance and submitting the dispensing data to the state PDMP.

How This Rating Was Determined
The rating reflects data provided by the National Alliance of Model State Drug Laws about state legal requirements for the timeliness of data submission to the state PDMP. CDC translated this information into a rating for each state. The rating does not reflect how fully the state has carried out the law. The “as of” date referenced—July 31, 2015—is the date CDC assessed the law. The date does not reflect when the law was enacted or became effective.

State requirement that prescribers must consult the patient’s PDMP history before initially prescribing opioid pain relievers and benzodiazepines, and at least every three months thereafter.

How This Rating Was Determined

The rating reflects data provided by the National Alliance of Model State Drug Laws and the PDMP Center of Excellence at Brandeis University about state laws requiring prescriber use of state PDMPs. CDC translated this information into a rating for each state. The rating does not reflect how fully the state has carried out the law. The “as of” date referenced—October 31, 2015—is the date CDC assessed the law. The date does not reflect when the law was enacted or became effective.

For the purposes of this report, a law was deemed to “require” a PDMP check when it applied to most or all prescribers. To be rated green, a state’s policy must have required a check for both opioid and benzodiazepine prescriptions; to be rated yellow, the requirement must have applied to at least opioid prescriptions.

Laws were considered to be requiring a PDMP check even if they had limited exceptions to the requirement (e.g., exempting prescriptions written in emergency departments) or if they exempted short prescriptions (i.e., lasting less than seven days). Laws that applied only to limited classes of providers (e.g., only opioid treatment programs or pain clinics) or that had overly broad exceptions (e.g., exempting prescriptions lasting 90 days or less), were not deemed as requiring PDMP checks in this report and were rated as red. In addition, laws in which the requirement depended on a subjective standard (e.g., the provider was required to check the PDMP only when having a reasonable belief of inappropriate use by the patient or only when treating chronic pain) were rated red.

State expansion of eligibility for Medicaid coverage of family planning services to include teens under age 18 years and to be set to at least the income eligibility level for coverage of pregnancy care (this level varies by state).

How This Rating Was Determined
The rating reflects the extent to which the state had expanded eligibility for Medicaid coverage of family planning services. A review of state Medicaid family planning waivers and state plan amendments (SPAs) was conducted to determine whether a state’s income eligibility level for family planning coverage was set to at least the same income level as for pregnancy care coverage (20,21). The income eligibility level for family planning services extended to applicants whose income was up to 5 percentage points above the set FPL for the following states: Alabama, Connecticut, Indiana, Louisiana, Mississippi, Missouri, Montana, New Hampshire, New Mexico, New York, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, Virginia, and Wisconsin. This review also examined the extent to which the state waiver or SPAs covered all teens, regardless of pregnancy status (20). In addition, a review was conducted of those states that had expanded their Medicaid programs under the ACA to cover adults aged <65 years with incomes up to 138% of the FPL (22). Teens aged ≤18 years with family incomes up to 138% of the FPL (or higher, depending on the state) are eligible for free or low-cost health coverage, including family planning services, in all states that have expanded Medicaid.