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America’s Most (and Least) Healthy States

Americans are by no means the healthiest people in the world. While there have been vast improvements in infant-mortality rates and smoking rates over the last several decades, the United States still struggles with obesity and diabetes in particular. Last year, the nation’s obesity rate increased to 29.4% of adults from 27.6% the year before.

The United Health Foundation’s 2014 Health Rankings report examined both determinants and health outcomes. It included such factors as healthy behaviors, quality of health care, health policy, the presence of diseases and deaths from illnesses across the nation. Health varies considerably between states. Based on this year’s edition of America’s Health Rankings, Hawaii and Mississippi are once again the healthiest and least healthy states.

Click here to see America’s Most (and Least) Healthy States

Negative health outcomes were far less common in the healthiest states than in the least healthy ones. The prevalence of diabetes has increased dramatically in the United States in recent years, due in part to rising obesity rates. In all of the healthiest states, the rates of diabetes were less than the national rate of nearly 10% of adults. In addition, the majority of the healthiest states were also among the 10 states with the fewest cardiovascular deaths per 100,000 people.

The cost of poor health can be measured in years of life. The Centers for Disease Control and Prevention (CDC) tracks premature deaths, as measured by the number of years lost when people do not live to age 75. This year, the CDC estimated that nearly 7,000 years were lost for every 100,000 Americans. This figure was lower in all of the healthiest states, one of which, Massachusetts, led the nation with 5,345 estimated years lost per 100,000 people.

Healthy behavior and lifestyle is also a major contributor to good health. According to Dr. Rhonda Randall, the chief medical officer for the United Retiree Solutions and a senior advisor to the United Health Foundation, the United States has tackled issues like infant mortality and smoking cessation. And “we can do that with physical inactivity and obesity. Those are things that are completely within our control,” Randall said. Less than 75% of Americans reported regular physical activity. In nine of the least healthy states, however, less than 70% of people exercised regularly.

Money and employment also clearly play roles in determining health. The healthiest states are often among the nation’s wealthiest, and each had a median household income above the national median in 2013. All but one of the healthiest states also had a lower unemployment rate than the national rate of 7.4% last year. Low unemployment rates improve the likelihood of receiving health insurance, as many Americans are covered through their work. All of the healthiest states also had better coverage rates than the national coverage rate. And in three of the 10 states, the percentage of residents without health coverage was less than half the national figure of 14.6%.

Yet, according to Randall, “We know that just having health insurance isn’t enough. It’s also access to care, and making good decisions for our lifestyle choices, and then the quality of clinical care we receive when we do access the health care system.” When it comes to the quality of clinical care, once again, the healthiest states stood out. Six of these 10 states were among the top 10 nationally for the concentration of primary care physicians, and Massachusetts had more than 200 doctors for every 100,000 residents, the highest figure in the country.

Randall went on to say that health really needs to be understood broadly. “It’s not just about whether you get the right care, or when you go to see your doctor, it’s also about the environment with which we live.” Environment, in this case, includes both promoting strong education and a safe environment. Ninth graders had relatively low chances of graduating high school in many of the of the least healthy states, for example. Additionally, the violent crime rates in many of these states were far higher than the national rate of 387 incidents per 100,000 people.

Public policy is yet another contributor. While the United States spent $90 per capita on public health services, several of the healthiest states — Hawaii, Vermont, Massachusetts, and North Dakota — spent more than $100 per resident. Yet, a majority of the healthiest states actually spent less per capita on public health than the nation as a whole. Randall explained that “public health spending is an important measure, which is why we included it. But, it’s also important how effective the programs are that the money is used for… It is multifaceted.”

Based on data provided by United Health Foundation’s America’s Health Rankings, 24/7 Wall St. examined the 10 states with the highest and lowest overall scores. These scores were based on a number of measures that fall into two separate categories: health determinants and health outcomes. Determinants were further divided into behaviors, such as smoking, community and environmental factors, such as children living in poverty; policy factors, such as public health funding and immunization rates; and clinical care factors, such as the availability of dentists and doctors. Outcomes included rates of death from cancer and cardiovascular diseases, as well as infant mortality rates. Additionally, we also reviewed supplementary data provided by America’s Health Rankings, including economic factors such as median household income based on the Current Population Suvey.

These are the healthiest states in America.

The Healthiest States in America

10. Nebraska
> Pct. obese: 29.6% (23rd highest)
> Cardiovascular deaths per 100,000: 224.9 (17th lowest)
> Physicians per 100,000: 118.5 (25th highest)
> Pct. visiting dentist in 2012: 63.4 (16th highest)

Based on a wide range of factors, Nebraska has the 10th healthiest population in the nation. As in most of the healthiest states, a strong job market is a major factor. Not only does job security alleviate financial stress and provide income needed to access health services, but also a large percentage of Americans receive health insurance from their employer. Less than 4% of Nebraska’s workforce was unemployed last year, nearly the lowest rate nationwide. Also, 11.3% of state residents did not have health insurance in 2013, one of the lower rates. By comparison, nearly 15% of Americans were not insured that year. Nebraskans also have relatively healthy behaviors. For example, there were just three drug-related deaths per 100,000 Nebraska residents last year, nearly half the national rate and less than all but two other states.

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9. North Dakota
> Pct. obese: 31.0% (13th highest)
> Cardiovascular deaths per 100,000: 226.8 (18th lowest)
> Physicians per 100,000: 123.6 (21st highest)
> Pct. visiting dentist in 2012: 56.1 (25th lowest)

North Dakota residents are still reaping the benefits from the state’s dramatic economic growth. North Dakota’s GDP has grown faster than that of any other state in the last several years, and its unemployment rate of 2.9% was the lowest in the nation last year. While low unemployment generally contributes to better health, it can also have negative impact on well-being. For example, nearly 24% of residents reported binge drinking — defined as consuming more than four drinks (for women) or five drinks (for men) in a single session — in the previous 30 days, by far the highest rate in the country. North Dakotans were also among the most likely Americans to report insufficient sleep, which could be due in part to long work days. Yet, the state’s strong economy seems to have led to overall positive health outcomes. Public health services were among the best funded in the country, contributing in part to a nearly 77% immunization rate for adolescents — the second highest rate in the United States.

8. Colorado
> Pct. obese: 21.3% (the lowest)
> Cardiovascular deaths per 100,000: 197.1 (2nd lowest)
> Physicians per 100,000: 120.7 (24th highest)
> Pct. visiting dentist in 2012: 69.4 (11th highest)

Like in the majority of the healthiest states, Colorado residents are among the wealthiest in the nation. A typical household in the state made $63,371 in 2013, more than in all but a handful of states. In addition to higher incomes, more than 82% of Colorado residents exercised on a regular basis, the highest percentage in the country. And this physical activity also likely contributed to the state’s low obesity rate. Just 21.3% of residents were obese as of last year, the lowest rate nationwide, and substantially less than the nearly 30% of all Americans considered obese. The low obesity rate, in turn, likely helped lower the prevalence of diabetes and cardiovascular disease in the state. There were less than 200 cardiovascular deaths per 100,000 people last year, and 6.5% of the adult population had been diagnosed with diabetes, the second-lowest and lowest rates, respectively.

7. New Hampshire
> Pct. obese: 26.7% (16th lowest)
> Cardiovascular deaths per 100,000: 213.8 (7th lowest)
> Physicians per 100,000: 135.7 (10th highest)
> Pct. visiting dentist in 2012: 64.9 (11th highest)

Despite relatively low health funding from the state, the infant mortality rate of 4.5 deaths per 1,000 live births in New Hampshire was among the lowest in the nation last year. There were less than 14 teen pregnancies per 1,000 females in New Hampshire, the lowest rate and less than half the national figure. Teen pregnancies tend to be unwanted and can have health consequences to mother and baby. Additionally, nearly three-quarters of teenagers in the state had been vaccinated as of 2013, one of the highest immunization rates reviewed. Infectious diseases such as chlamydia were less likely in New Hampshire than in the vast majority of states. Residents also live in some of the safest neighborhoods in the country. There were 188 violent crimes per 100,000 New Hampshire residents last year, less than half the national rate and nearly the lowest.

6. Minnesota
> Pct. obese: 25.5% (10th lowest)
> Cardiovascular deaths per 100,000: 184.7 (the lowest)
> Physicians per 100,000: 145.2 (7th highest)
> Pct. visiting dentist in 2012: 62.4 (17th highest)

Minnesota had the lowest rate of cardiovascular deaths in the nation, at just 184.7 per 100,000 people. In all, just 5,358 years of life were lost for every 100,000 people due to premature deaths, defined as deaths that occur before age 75. By contrast, almost 7,000 years of life were lost for every 100,000 people nationwide. The state’s high-quality clinical care likely contributed to favorable health outcomes. Few states had a higher concentration of primary care physicians or fewer preventable hospitalizations relative to the number of Medicare beneficiaries. Binge drinking is one of the few metrics in which the state fared poorly. Twenty-one percent of the state’s adult population binge drinks, fifth worst in the nation.

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5. Utah
> Pct. obese: 24.1% (4th lowest)
> Cardiovascular deaths per 100,000: 212.2 (6th lowest)
> Physicians per 100,000: 80.8 (7th lowest)
> Pct. visiting dentist in 2012: 67.3 (13th highest)

While high levels of binge drinking are a weakness in many of the nation’s healthiest states, just 12.3% of Utah adults reported binge drinking in the previous month, nearly the lowest rate. Also, slightly more than 10% of Utah residents were smokers, the lowest rate nationwide. And nearly 80% of people exercised regularly, one of the highest figures nationwide. With a median household income of nearly $63,000 last year, Utah residents were among the nation’s wealthiest. High incomes help Utah households afford healthier food, medicine, and medical care. Income was also more evenly distributed in Utah than in the vast majority of states. As in the majority of healthy states, Utah residents were also in relatively good physical health. The state had the nation’s lowest concentration of deaths from cancer as well as the second lowest rate of adults with diabetes.

4. Connecticut
> Pct. obese: 24.9% (8th highest)
> Cardiovascular deaths per 100,000: 216.5 (11th lowest)
> Physicians per 100,000: 166.7 (6th highest)
> Pct. visiting dentist in 2012: 79.1 (6th highest)

Connecticut had one of the nation’s lowest smoking rates, at just 15.5% of the adult population. The state also had one of the lowest obesity rates in the United States, at just under 25% of the adult population. In recent decades these rates have moved in opposite directions. Just as in the rest of the country, smoking rates in Connecticut have declined, while obesity rates have risen. The state also fared well in health determinants related to both policy and clinical care. The child immunization rate of 78.2% and the adolescent immunization rate of 73.8% were both among the highest in the nation. Further, Connecticut had the sixth highest concentrations of both primary care doctors and dentists, at 166.7 and 79.1 per 100,000 people, respectively.

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3. Massachusetts
> Pct. obese: 23.6% (3rd highest)
> Cardiovascular deaths per 100,000: 206.9 (4th lowest)
> Physicians per 100,000: 200.8 (the highest)
> Pct. visiting dentist in 2012: 85.6 (the highest)

Massachusetts had the lowest rate of people without health care coverage in the nation, at just 3.8% of the population. By comparison, nearly 15% of all Americans lacked health insurance. In addition to having a largely insured population, Massachusetts also had the highest concentration of primary care physicians in the U.S., at more than 200 for every 100,000 residents, as well as the highest concentration of dentists, at 85.6 per 100,000 people. Low rates of smoking, obesity, and physical inactivity also helped residents stay healthy. High levels of immunization, too, helped promote good health. More than 78% of young children aged received the recommended doses of key vaccines. Immunization coverage among adolescents was also quite high, at 74.6%.

2. Vermont
> Pct. obese: 24.7% (7th lowest)
> Cardiovascular deaths per 100,000: 218.4 (13th lowest)
> Physicians per 100,000: 170.9 (4th highest)
> Pct. visiting dentist in 2012: 60.0 (21st highest)

Vermont, which consistently ranks among the healthiest states, trails only Hawaii for the third consecutive year. While poor diet and physical inactivity are major contributors to poor health, both were relatively uncommon behaviors among Vermonters. Residents consumed more than two servings of vegetables daily on average, and nearly 80% exercised regularly, both higher figures than in all but a few states. In addition, less than 7% of residents did not have health insurance last year, nearly the best coverage rate nationwide. State residents also perceived their own health better than residents of any other state, with nearly 62% claiming they were in excellent health. However, incidents of infectious diseases like pertussis, or whooping cough — the prevalence of which increased across the nation — was relatively common in Vermont.

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1. Hawaii
> Pct. obese: 21.8% (2nd lowest)
> Cardiovascular deaths per 100,000: 199.1 (3rd lowest)
> Physicians per 100,000: 140.2 (9th highest)
> Pct. visiting dentist in 2012: 79.2 (5th highest)

Hawaii is, again, the healthiest state in the nation. A major reason is Hawaii’s dedication to promoting good health through policy. Just 6.8% of Hawaii’s population was not insured last year, tied for second-best nationwide, and the state provided more than $212 per person in public health funding per person, behind only Alaska. By comparison, nearly 15% of Americans across the country were uninsured and, on average, states’ public health funding totalled just $90 per person. Beyond just policy, Hawaiians were among the least likely Americans to be obese or to smoke. Preventable hospitalizations were the lowest in the nation at just 28.2 per 1,000 medicare beneficiaries, compared to 62.9 per 1,000 beneficiaries nationwide. The total effect of these factors has made Hawaii exceptionally healthy. The state had just 199.1 cardiovascular deaths and 155.3 cancer deaths per 100,000 people, both among the lowest rates.

The Least Healthy States in America

10. Indiana
> Pct. obese: 31.8% (9th highest)
> Cardiovascular deaths per 100,000: 274.4 (12th highest)
> Physicians per 100,000: 104.2 (14th lowest)
> Pct. visiting dentist in 2012: 48.6 (9th lowest)

Based on health outcomes and various health determinants, Indiana was identified as the 10th least healthy state in America. Like all of the unhealthy states, Indiana residents struggled with obesity. The state’s obesity rate of nearly 32% was the ninth highest rate in the country. While 75% of Americans nationwide reported exercising regularly, less than 70% of Indiana residents did, one of the lower figures reviewed. Environmental factors also contributed to the state’s poor health ranking. Residents were exposed to nearly 12 microns of particulate matter found in smoke or haze on average, more than in all but one other state. While the state’s public health services were among the most underfunded nationwide, nearly 73% of adolescents in the state had received vaccinations as of last year, one of the higher immunization rates in the nation.

9. South Carolina
> Pct. obese: 31.7% (10th highest)
> Cardiovascular deaths per 100,000: 272.2 (14th highest)
> Physicians per 100,000: 107.9 (18th lowest)
> Pct. visiting dentist in 2012: 47.6 (7th lowest)

There were nearly 560 violent crimes reported per 100,000 South Carolina residents last year, more than in all but four other states. A high violent crime rate can not only increase the risk of bodily injury and death, but it can also cause mental health issues and long-term stress for families, neighborhoods, and children. Infectious diseases were also more common in South Carolina than in many other states. For example, there were 580 cases of chlamydia and 31.1 cases of salmonella per 100,000 residents, both the fifth highest rates nationwide. Likely brought on by the state’s high obesity rate, 12.5% of residents had diabetes last year, nearly the highest rate in the nation.

8. Alabama
> Pct. obese: 32.4% (8th highest)
> Cardiovascular deaths per 100,000: 329.2 (2nd highest)
> Physicians per 100,000: 101.9 (11th lowest)
> Pct. visiting dentist in 2012: 43.8 (3rd lowest)

Alabama residents had the second highest rate of cardiovascular deaths, at nearly 330 per 100,000 people. High cholesterol and high blood pressure were common more in Alabama than in almost any other state. The prevalence of these risk factors contributed to high rates of heart disease and stroke. In all, more than 10,000 years of life were lost for every 100,000 people due to premature deaths — defined as deaths that occur before age 75. Alabama’s infant mortality rate of 8.6 deaths per 1,000 live births was also worse than all but one state. As in a majority of unhealthy states, low incomes may partly contribute to poor health outcomes. A typical household in Alabama made $41,381 in 2013, among the lowest median household incomes nationwide.

7. West Virginia
> Pct. obese: 35.1% (the highest)
> Cardiovascular deaths per 100,000: 303.7 (6th highest)
> Physicians per 100,000: 107.8 (17th lowest)
> Pct. visiting dentist in 2012: 47.3 (5th lowest)

More than 27% of West Virginians reported a smoking habit last year, the highest smoking rate in the nation. Tobacco habits normally start fairly early in life, and youth smoking was quite common in West Virginia. Nearly one in five high school-age state residents had smoked at least once in the previous 30 days, also the highest rate in the country. It’s not just tobacco that West Virginians abuse. There were an alarming 31.3 drug-related deaths per 100,000 state residents last year, by far the worst rate nationwide. In addition, there were 220 cancer deaths per 100,000 state residents, the third highest rate among all states reviewed.

6. Tennessee
> Pct. obese: 33.7% (4th highest)
> Cardiovascular deaths per 100,000: 300.6 (7th highest)
> Physicians per 100,000: 124.4 (19th highest)
> Pct. visiting dentist in 2012: 50.9 (15th lowest)

More than one-third of Tennessee adults and nearly 17% of adolescents were considered obese last year, both the fourth highest rates nationwide. As in most states, the obesity problem in Tennessee has worsened considerably. Physical inactivity was likely a major contributor. Less than 63% reported routine exercise, less than in all but one other state. Residents also had among the highest rates of heart attacks, and there were more than 300 cardiovascular deaths per 100,000 people, one of the highest rates. Determinants such as a struggling economy and safety concerns also played a role in the state’s poor ranking. More than 8% of Tennessee’s workforce was unemployed in 2013, one of the highest rates nationwide. The state also had the nation’s worst crime rate, at 643.6 violent crimes per 100,000 people in 2013.

5. Oklahoma
> Pct. obese: 32.5% (7th highest)
> Cardiovascular deaths per 100,000: 322.0 (3rd highest)
> Physicians per 100,000: 84.8 (3rd lowest)
> Pct. visiting dentist in 2012: 50.2 (14th lowest)

Less than 63% of children in Oklahoma had been vaccinated, one of the worst rates of any states. Also, 18% of residents did not have health insurance last year, one of the higher rates reviewed. The state’s public health system received about $79 per capita in public funding, one of the nation’s lower rates. Even more scarce than funding was access to a primary care doctors. There were less than 85 primary care physicians per 100,000 residents in Oklahoma, a lower rate than in all but two other states. Policies and clinical care measures like these tend to result in worse health outcomes for residents. Chronic conditions such as high blood pressure and high cholesterol were more common in Oklahoma than in the vast majority of states. There were also 322 cardiovascular deaths per 100,000 Oklahoma residents, the third worst rate in the nation.

4. Kentucky
> Pct. obese: 33.2% (5th highest)
> Cardiovascular deaths per 100,000: 297.3 (8th highest)
> Physicians per 100,000: 103.0 (13th lowest)
> Pct. visiting dentist in 2012: 56.4 (25th highest)

While nationally cancer deaths have fallen 4% since 1990 to a rate of 189 per 100,000 Americans, the prevalence of cancer in Kentucky remain stubbornly high. Kentucky led the nation with 228 cancer deaths per 100,000 people. The popularity of tobacco in the state likely contributed to the cancer death rate. More than 26% of residents reported a smoking habit, a higher rate than in every state except for West Virginia. Residents also struggled with obesity. Nearly a third of residents were considered obese, one of the highest rates nationwide. Kentucky also led the nation for youth obesity, with 18% of teenagers considered obese. Economic factors likely play a role in the state’s poor health outcomes. For example, nearly 32% of children in Kentucky lived in poverty last year, the worst rate nationwide.

3. Louisiana
> Pct. obese: 33.1% (6th highest)
> Cardiovascular deaths per 100,000: 307.5 (5th highest)
> Physicians per 100,000: 123.7 (20th highest)
> Pct. visiting dentist in 2012: 49.6 (12th lowest)

Like all of the least healthy states, Louisiana’s obesity rate was relatively high last year. More than 33% of adults were considered obese, the sixth highest rate. While the national obesity rate rose from a year ago, it actually fell slightly in Louisiana from the year before. Poor diets among state residents also contributed to Louisiana’s low health ranking. On average, residents in only one other state consumed less vegetables daily than people in Louisiana. Smoking was also more common in Louisiana than in all but a handful of states. Unhealthy habits tend to be more common in poorly educated populations. The four-year graduation rate for Louisiana ninth graders was 72%, worse than in all but four other states. Louisiana households were also the poorest in the nation with a median household income of less than $40,000 in 2013.

2. Arkansas
> Pct. obese: 34.6% (3rd highest)
> Cardiovascular deaths per 100,000: 313.7 (4th highest)
> Physicians per 100,000: 102.6 (12th lowest)
> Pct. visiting dentist in 2012: 41.7 (the lowest)

While more than 70% of children had been immunized nationwide in 2013, just 57% of children in Arkansas were vaccinated, the worst rate in the country. Arkansas residents were also the least likely to make an annual visit to the dentist, with less than 55% doing so last year. And like all unhealthy states, Arkansas residents struggled with obesity. Nearly 35% of state residents were considered obese last year, the third highest rate nationwide. Nearly 18% of high school-aged residents were also considered obese, the second-highest rate. Low incomes likely contributed in part to poor health outcomes. A typical household made $39,919 in 2013, less than every state except for Louisiana.

1. Mississippi
> Pct. obese: 35.1% (the highest)
> Cardiovascular deaths per 100,000: 346.0 (the highest)
> Physicians per 100,000: 81.8 (2nd lowest)
> Pct. visiting dentist in 2012: 41.9 (2nd lowest)

Mississippi is once again the least healthy state in the nation. More than 35% of residents were obese last year, the highest rate in the U.S. This was likely due in part to just 61.9% of residents reporting exercising routinely, the lowest rate nationwide. Based on daily vegetable consumption, Mississippians also had the worst diets in the country. In terms of clinical care, the state is in need of improvement. There were 41.9 dentists and 81.8 primary care physicians per 100,000 people, both the second-lowest rates in the country. Premature death was estimated to have cost roughly 10,354 years of life for every 100,000 residents, the highest figure reviewed. Specifically, there were 346 cardiovascular deaths per 100,000 people, the highest in the nation. Yet another example of the residents’ poor health and of Mississippi’s poor quality health care system is the infant mortality rate, which, at 9.1 deaths per 1,000 live births, was the worst rate in the country.