PSRs by State*

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.

As of January 1, 2014, Massachusetts's excise tax per gallon of beer was $0.11 (12).

Community Preventive Services Task Force recommendation: Increase alcohol taxes (7). Studies show that a 10% increase in the price of beer would likely reduce beer consumption by approximately 5% (7). Doubling alcohol taxes could reduce alcohol-related mortality by an average of 35% (13).

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.

As of January 1, 2014, Massachusetts's excise tax per gallon of distilled spirits was $4.05 (14).

Community Preventive Services Task Force recommendation: Increase alcohol taxes (7). Studies show that a 10% increase in the price of distilled spirits would likely reduce distilled spirits consumption by approximately 8% (7). Doubling alcohol taxes could reduce alcohol-related mortality by an average of 35% (13).

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.

As of January 1, 2014, Massachusetts's excise tax per gallon of wine was $0.55 (15).

Community Preventive Services Task Force recommendation: Increase alcohol taxes (7). Studies show that a 10% increase in the price of wine would likely reduce wine consumption by approximately 6% (7). Doubling alcohol taxes could reduce alcohol-related mortality by an average of 35% (13).

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.

As of January 1, 2015, Massachusetts had commercial host liability with no major limitations (16–18).

Community Preventive Services Task Force recommendation: Commercial host (dram shop) liability for illegal sales or service of alcohol (8). Evidence shows these laws are associated with a reduction in alcohol-related harms, including a median 6.4% reduction in deaths from motor vehicle crashes (8).

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.

In 2014, Massachusetts tested 95.1% of E. coli  O157 cases within 4 days (8).

CDC target: Testing of ≥90% of annual reported E. coli  O157 cases within four days. The CDC Public Health Emergency Preparedness Cooperative Agreement, which provides federal funding to state, local, tribal, and territorial health departments, has two national laboratory performance targets for food safety, including the E. coli  testing target. Performing DNA fingerprinting as quickly as possible for all Shiga toxin-producing E. coli  improves outbreak detection, helps prevent additional cases, and identifies prevention and control measures for food regulatory agencies and the food industry (2).

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.

In 2014, Massachusetts tested 96.7% of reported Salmonella  cases (8,9).

Research and experts in the field agree that performing DNA fingerprinting of all Salmonella  cases would improve outbreak detection, help prevent additional cases, and identify prevention and control measures for food regulatory agencies and the food industry (2).

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.

As of September 2014, Massachusetts had adopted three of the four selected provisions in the 2013 FDA Food Code: prohibiting bare hand contact with ready-to-eat food, requiring at least one employee in a food service establishment to be a certified food protection manager, and requiring food service employees to wash their hands (10).

The FDA publishes model food safety practices to prevent transmission of norovirus and other foodborne illnesses, but adoption is at the discretion of state governments (3). CDC has identified four provisions that are critical to reducing foodborne illnesses (11):

• Excluding ill food service staff from working until at least 24 hours after symptoms of vomiting and diarrhea have ended (section 2-2 of the 2013 FDA Food Code)
• Prohibiting bare hand contact with ready-to-eat food (section 3-301.11)
• Requiring at least one employee in a food service establishment to be a certified food protection manager (sections 2-102.12 and 2-102.20)
• Requiring food service employees to wash their hands (section 2-3)

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).

As of July 31, 2015, Massachusetts's HAI activities addressed all four prevention areas (11).

HHS’s HAI action plan sets national goals and targets for reducing and preventing HAIs (6). CDC helps states achieve these targets by providing technical expertise and assistance in addressing the following prevention areas: HAI partnerships, outbreak response, training, and data validation. State programs that address these four areas are critical for reducing HAIs (6). Increasing states’ capacity to prevent HAIs can reduce illnesses, save money, and improve healthcare quality for patients (6).

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).

As of December 2014, 58.2% of acute care hospitals in Massachusetts reported having antibiotic stewardship programs that incorporated all 7 core elements deemed critical by CDC (9).

The White House’s National Strategy and Action Plan for fighting antibiotic resistance encourage the use of antibiotic stewardship programs to ensure and improve the judicious use of antibiotics (7,8). AR infections prolong hospitalizations and increase costs, disabilities, and deaths. Inappropriate antibiotic use is a major cause of these infections. Stewardship programs in acute care hospitals are critical to improving antibiotic use and prescribing practices, ensuring optimal treatment of patients, and prolonging the time antibiotics are effective (4). Stewardship programs can reduce AR infections, C. difficile infections, and antibiotic adverse events; decrease drug and healthcare costs; and improve healthcare quality for patients.

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).

As of December 2014, 76.6% of office-based physicians in Massachusetts demonstrated meaningful use of EHRs (15).

According to the Institute of Medicine, using electronic health records supports high-quality primary care (10). The Community Preventive Services Task Force recommends clinical decision-support systems, which are used in certified EHR technology, for prevention of cardiovascular disease (13). Research shows that meaningful use of EHRs allows physicians, nurses, pharmacists, and other healthcare providers to proactively monitor and manage the health of their patients by tracking heart disease and stroke risk factors (16–23). “Meaningful use” involves using EHRs to 1) improve quality, safety, and efficiency; 2) engage patients and family; 3) improve care coordination; 4) maintain privacy and security of patient health information; 5) improve population and public health; and 6) reduce health disparities (23).

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).

As of December 31, 2014, Massachusetts had a statewide pharmacist CDTM policy for all health conditions, with certain limitations in community pharmacy settings (25).

The Community Preventive Services Task Force recommends team-based care to improve blood pressure control (8). State policies such as CDTM laws, which authorize pharmacists to enter into collaborative practice agreements with prescribing providers, can increase medication adherence rates and improve health outcomes (e.g., reduced hemoglobin A1c, lower blood pressure and LDL cholesterol level, fewer adverse drug events) (9).

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.)

As of May 12, 2015, Massachusetts's Medicaid program reimbursed for routine HIV screening of persons aged 15–65 years, regardless of risk (7,12).

CDC/US Preventive Services Task Force recommendation: HIV screening of adolescents, adults, and pregnant women, regardless of risk (8,9). All state Medicaid programs cover medically necessary HIV testing (7). Reimbursement for routine screening—meaning broad, population-based HIV screening, in contrast with medically necessary testing and screening targeted at those at higher risk—increases the availability of this important preventive service for low-income populations (5,13).

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).

As of January 2015, Massachusetts's HIV testing law was consistent with CDC's 2006 HIV testing recommendations (8,10).

CDC recommendation: HIV testing of all people aged 13–64 years (8). HIV testing enables individuals with HIV to become aware of their health status and to access medical care and treatment. Studies show that people diagnosed with HIV are less likely to transmit HIV to others (16). State laws can facilitate access to HIV testing.

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.

As of December 2014, Massachusetts required reporting of all CD4 and all viral load results (including undetectable results) but reported incomplete data to CDC (10,11).

CD4 results (providing a measure of a person’s immune function) and HIV viral load data (measuring the amount of virus in a person’s blood) provide critical data for the management of medical care and health of people living with HIV. These data are also used to monitor progress toward achieving the goals of the National HIV/AIDS Strategy and to ensure that people living with HIV are linked to HIV medical care and retained in care (2).

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.

Massachusetts was not rated for this indicator because incomplete data for CD4 and viral load test results were reported to CDC (10,11).

Viral suppression is a primary goal of HIV treatment. Having a suppressed viral load improves one’s health, increases one’s chance of survival, and reduces one’s risk of transmitting HIV. A target of 80% of persons with HIV having viral suppression is consistent with the updated 2020 National HIV/AIDS Strategy and aligns with the 90-90-90 goals set by the Joint United Nations Programme on HIV/AIDS (2,18).

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.

As of July 1, 2015, Massachusetts had a secondary enforcement seat belt law (28).

Task Force on Community Preventive Services recommendation: Primary enforcement seat belt laws are recommended on the basis of strong evidence that they are substantially more effective than secondary enforcement laws at reducing motor vehicle-related injuries and deaths (9). Seat belt use rates are an average of 9–14 percentage points higher in primary enforcement states than in secondary enforcement states (9,21–23).

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.

As of July 1, 2015, Massachusetts required that all motor vehicle passengers aged ≤7 years be buckled in a car seat or booster seat (28).

Evidence shows that laws mandating the use of car seats and booster seats increase their use (10). Increasing the required age for car seat or booster seat use is an effective way to keep children protected. For example, among states that increased the required age to 7 or 8 years, car seat and booster seat use tripled (11).

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.

As of July 1, 2015, the minimum age for acquiring a learner's permit in Massachusetts was 16 years (29).

A minimum age of 16 years for a learner’s permit is one of the five recommended components of a comprehensive GDL system (13–16,19).

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.

As of July 1, 2015, the mandatory holding period for a learner's permit in Massachusetts was 6 months (29).

A 12-month holding period for a learner’s permit is one of the five recommended components of a comprehensive GDL system (12,14,16,19).

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.

As of July 1, 2015, Massachusetts had a restriction for intermediate or provisional license holders against nighttime driving between 12:30 am and 5:00 am (29).

A restriction against nighttime driving between 10:00 pm and 5:00 am (or longer) is one of the five recommended components of a comprehensive GDL system (12,14,16,17,19).

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.

As of July 1, 2015, Massachusetts limited to zero the number of young passengers who can ride with intermediate or provisional license holders without adult supervision (29).

A limit of zero or one on the number of young passengers who can ride with an intermediate or provisional license holder is one of the five recommended components of a comprehensive GDL system (12,14,16,17,19).

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.

As of July 1, 2015, Massachusetts lifted nighttime restrictions beginning at age 18 years and young passenger restrictions beginning at 17 years (29).

A minimum age of 18 years for unrestricted licensure is one of the five recommended components of a comprehensive GDL system (12,14,16,17,19).

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.

As of July 1, 2015, Massachusetts required ignition interlocks for repeat offenders convicted of alcohol-impaired driving (30).

Task Force on Community Preventive Services recommendation: Use of ignition interlocks is recommended for all people convicted of alcohol-impaired driving on the basis of strong evidence of interlocks’ effectiveness in reducing re-arrest rates while the interlocks are installed (20).

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.

In 2014, 81.4% of secondary schools in Massachusetts did not sell the following items in vending machines or at school stores, canteens, or snack bars: candy, baked goods that are not low in fat, salty snacks that are not low in fat, soda pop, or fruit drinks that are not 100% juice (19).

In addition to providing school meals, many schools offer foods and beverages in venues such as school stores, canteens, snack bars, and vending machines. The USDA’s regulation commonly known as Smart Snacks in School requires that all foods and beverages sold at school during the school day meet federally defined nutrition standards (20). These standards were implemented in school year 2014–2015 for schools participating in the federal school meal programs and apply to foods and beverages sold a la carte, in the school store, and in vending machines.

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).

As of February 2015, Massachusetts did not have a nutrition standards policy for sale of foods and beverages (21).

The Institute of Medicine recommends that government agencies implement “strong nutrition standards for all foods and beverages sold or provided through the government” and ensure “that healthy options are available in all places frequented by the public” to reduce the availability of less healthy foods and beverages and increase the availability of more healthy options (11).

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.

In 2014, Massachusetts's state licensing regulations for childcare facilities included 8 of the 47 components of national standards for obesity prevention (23).

Building on a comprehensive set of national standards defined in 2011 (15), the National Resource Center for Health and Safety in Child Care and Early Education has identified 47 licensing standards components considered to have a high impact for obesity prevention (24). These components include nutrition, physical activity, screen time, and infant feeding in licensed childcare settings (24). In addition, the Institute of Medicine has recommended that childcare regulations include requirements related to physical activity, sedentary activity, and child feeding (12).

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.

In 2013, Massachusetts had an average birth facility score of 84 out of a possible 100 (25).

The US Surgeon General recommends that maternity care practices throughout the United States fully support breastfeeding (13). A review of evidence by the Cochrane Collaboration found that institutional changes in maternity care practices effectively increased breastfeeding initiation and duration rates (26).

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.

As of July 31, 2015, Massachusetts required that dispensing data be submitted to the PDMP within 7 days (8).

Requiring timely submission of drug dispensing data to PDMPs is an important policy to enable informed prescribing and help identify questionable activity (5). When pharmacists dispense controlled substances to patients, they have to enter the prescription into the state PDMP system. However, states vary in how quickly they require pharmacies to submit these data to the PDMPs. Required intervals can range from one month to one day or even “real-time” (i.e., less than five minutes). When there is a significant time lag between dispensing a prescription and submitting data to the state PDMP, providers and other PDMP users lack information about patients’ most recent prescriptions. Delayed data submission reduces the usefulness of the prescription history data and has implications for patient safety and public health.

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.

As of October 31, 2015, Massachusetts required prescribers to consult the PDMP before initially prescribing opioids and benzodiazepines but did not require a subsequent check (9).

PDMPs are promising tools, allowing healthcare providers to see patients’ prescription histories to inform their prescribing decisions. However, a PDMP is useful to healthcare providers only if they check the system before prescribing, and checking the PDMP prior to prescribing opioid pain relievers and benzodiazepines is particularly important. States have sought to increase PDMP use by requiring providers to consult the PDMP before initially prescribing opioids and benzodiazepines. These policies have significant potential for maximizing the usefulness and promise of PDMPs as a clinical decision support tool (7,10).

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).

As of October 2015, Massachusetts had expanded Medicaid coverage through the ACA to include family planning services for all teens and adults with incomes up to 138% of the federal poverty level (FPL). The expansion did not include all teens and adults with incomes up to 205% of the FPL, the state's income level for pregnancy-related Medicaid coverage (20–22).

Healthy People 2020  objectives: 1) Increase the number of states that set the income eligibility level for Medicaid-covered family planning services to at least the same level used to determine eligibility for Medicaid-covered pregnancy-related care and 2) Increase the proportion of sexually experienced females aged 15–44 years who received reproductive health services in the past 12 months (15). Income-based Medicaid expansions have been shown to be effective in reducing births among teens aged 15–19 years (8–11).

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.