Minnesota's longstanding reputation as one of the healthiest states has taken a hit in recent years, and now the state has fallen to seventh place in a widely watched national ranking — its lowest spot in the survey's 29 years.

Although many strengths keep Minnesota in the top 10, America's Health Rankings cited excessive drinking, a low childhood immunization rate and increases in obesity and infant mortality as troubling indicators.

Like other states, Minnesota has also seen a surge in drug overdoses, with a 100 percent increase in the drug death rate over the past 10 years.

Minnesota occupied either first or second place for eight consecutive years in the early part of this century, according to the analysis by the United Health Foundation, which was established by Minnetonka-based UnitedHealth Group.

Since then, it has gradually fallen behind, with Hawaii and Massachusetts grabbing the top slots in this year's analysis.

"Minnesota continues to perform better than most states when it comes to health metrics," said state Health Commissioner Jan Malcolm. "However, our ranking … has dropped a bit in recent years and we continue to face serious challenges and disparities that must be addressed."

Even though Minnesota is among the 10 healthiest states, it continues to have wide disparities in health outcomes between its white and minority populations — something that is hidden by the overall ranking.

Among the 35 measures examined, Minnesota excelled for relatively high rates of health insurance, low child poverty, a low smoking rate and a low cardiovascular death rate.

But for childhood immunizations, just 66 percent of young children in Minnesota got the complete set of recommended shots, which was the 48th lowest rate in the country.

Minnesota also posted a high rate of excessive drinking. With nearly 22 percent of adults surveyed acknowledging either binge or chronic alcohol consumption, Minnesota tied with Nebraska for the 46th spot, followed by Iowa, North Dakota and Wisconsin, which placed last.

"In terms of alcohol-related problems, usually we think of traffic crashes," said Traci Toomey, a professor at the University of Minnesota School of Public Health. "There is a whole range of things that alcohol contributes to on a health basis, including medical costs."

She noted, however, that many people who drink to excess do not meet the clinical definition of alcohol addiction or dependence.

"There are so many more people that are drinking to excess that are not addicted," she said. "There are so many more of them that they contribute to more problems."

Public health efforts to address the problem include educating bartenders and restaurant managers to watch for warning signs of intoxication, Toomey said. But more needs to be done to help people learn how to consume alcohol safely.

"There is a general discomfort when we talk about it," said Toomey. "My work is a buzzkill if I go to a party and people ask me what I do for a living."

Heavy recent emphasis on opioid abuse has also diverted attention away from alcohol, said Dr. Robert Levy, a family practitioner and addiction specialist at the U.

"In Minnesota, we have done a good job around the opioid problem," he said. "In terms of primary care, we have taken our eye off the alcohol problem."

Another challenge is that doctors have less time to spend with patients, Levy said.

"It doesn't matter if you are working class or wealthy, your primary care provider is still subject to the same time constraints and doesn't educate you as much about healthy alcohol use," he said.

Shift in vaccinations?

Minnesota's low childhood immunization rates are a concern for the state health department, but officials said the measure used by the UnitedHealth Foundation analysis does not tell the whole story because it doesn't capture children at ages 4 and 5.

"More than 90 percent of parents vaccinate their kids," said Kris Ehresmann, infectious disease director at the Minnesota Department of Health. "When we look at children coming into school, we know that they are vaccinated."

The rankings analysis relied on a federal survey that measured whether children ages 19 to 35 months had received the full complement of nine recommended vaccines. Any who had failed to receive one of those vaccines was considered incomplete.

That could reflect a trend of some families to delay shots, Ehresmann said. But, she added, most children get vaccinated by the time they enroll in school.

"The people who don't vaccinate are not the norm," she said. "They are a small outlier, but an outlier that has grown, so we are concerned about that."

In addition, she noted, Minnesota is not seeing a surge in illnesses that could be prevented by vaccinations. One notable exception was the 2017 measles outbreak, which mostly affected young children who had not received the protective MMR vaccine (for measles, mumps and rubella).

"The majority of the families that … refuse something like an MMR end up giving the immunization by the time the child starts kindergarten," said Dr. Sheldon Berkowitz, a pediatrician at Children's Minnesota hospital and clinics. "It is rare that we see kids that aren't being immunized at all."

The Minnesota Chapter of the American Academy of Pediatrics supports proposals that would require parents to get medical counseling before refusing shots. Under current state law, parents can turn down shots for medical or personal reasons.

"Pretty much anybody can opt out for any reason," said Berkowitz, who is president-elect of the chapter. Some states already require patients to meet with a clinician, while a few allow exemptions only for medical reasons.

Glenn Howatt • 612-673-7192 Twitter: @GlennHowatt