The long debate over the Affordable Care Act (ACA) has, if nothing else, put the spotlight on the poor state of the country’s health and health care system. The United States ranks behind most developed nations in life expectancy despite spending more per capita on health care than any other country.

Across the country, health outcomes vary greatly. More than 30% of the adult population of Madera, California, reported being in less than optimal health, while only 6.4% said the same in Ames, Iowa, the healthiest city in the country by our measure. This vast disparity is one issue the ACA is, at least in part, intended to address. Cities such as Ames — that have populations with extremely high physical and mental well-being — can teach us much about what is necessary to create healthier populations — be it income, healthy behavior, or access to care. 24/7 Wall St. created an index to identify the least healthy city in each state.

Click here to see the least healthy city in every state

Click here to see the healthiest city in every state

Each city was ranked based on overall health outcomes, including length and quality of life. Also considered in the index are a range of factors that influence these outcomes, including healthy behaviors, clinical care, social and economic indicators, and physical environment.

While the least healthy city in most states tends to be unhealthy compared to the country as a whole, this is not always the case. And while urban dwelling has many positive impacts on the health of a population — including access to healthy food, places to exercise, and job opportunities — even large metro areas earned the distinction of a state’s least healthy city.

In states such as Minnesota and Hawaii, the least healthy metro area scored better than the national levels in most key health metrics. For the most part, however, these cities have poor health outcomes.

Not surprisingly, unhealthy behaviors tend to correlate strongly with less healthy populations. High rates of inactivity, for example, were especially common in these cities compared to the national levels of inactivity. Obesity, too, correlates very strongly with many of the leading causes of death in this country, and in many of the most unhealthy cities the obesity rates were higher than the national rate. Smoking also appears to be an important health indicator. Less than a third of the most unhealthy cities in each state had below national average smoking rates.

Many of the least healthy cities had low rates of health insurance coverage. There are several reasons for this, explained Bridget Catlin, co-director of the County Health Rankings and Roadmaps Program. While people without insurance can still access care, they “have to go to the places that will take them.” Those with insurance, on the other hand, find it easier to access care, and they have “choice of care [and] resources available to them.”

Another important factor in the least healthy metro areas is education. The vast majority of city with relatively unhealthy populations has below average rates of adults who have completed at least some college. Better-educated populations are more likely to make better health decisions, but education also comes into play in other ways.

“Education definitely contributes to decision-making, but it also contributes to income and then opportunity,” Catlin said. Better-educated people often work in better-paying jobs, which allows them easier access to healthy food and exercise options — much more than people with lower incomes. “There are multiple pathways going on here, but education is at the crux of increasing people’s opportunity for leading a healthier life.”

24/7 Wall St. created an index modelled after analysis conducted by County Health Rankings & Roadmaps, a Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute joint program. To identify the healthiest city in each state, 24/7 Wall St. reviewed all U.S. metropolitan statistical areas. The index rankings are based on overall health outcomes, a weighted composite of length of life, quality of life, and overall health factors. The health factors component is itself a weighted composite of healthy behaviors, clinical care, social and economic factors, and physical environment measures.

These are the least healthy cities in every state.

1. Gadsden, Alabama
> Pct. without health insurance: 14.2%
> Pct. food insecure: 8.6%
> Obesity rate: 33.8%
> 2014 unemployment rate: 7.0%

Alabama is one of the nation’s least healthy states. So Gadsden, the state’s least healthy metro area, is also one of the least healthy areas in the nation. Nearly 23% of Gadsden adults reported fair or poor health, higher than the comparable state rate of 20.5%, which itself was the fourth highest such level of poor health compared to other states. An estimated 9,508 years of life are lost annually per 100,000 people in Alabama, the third highest statewide level of premature death. In Gadsden, preventable deaths resulted in an estimated 11,057 years of life lost per 100,000 area residents.

2. Anchorage, Alaska
> Pct. without health insurance: 17.2%
> Pct. food insecure: 4.9%
> Obesity rate: 27.9%
> 2014 unemployment rate: 5.8%

Anchorage and Fairbanks are the only two metro areas in Alaska, and Anchorage earns the distinction of least healthy. However, as is the case across the nation, residents living in more urban areas tend to be healthier than residents living in more rural areas. As a result, even though Anchorage is the least healthy urban area in Alaska, it still performs better than the rest of the state in several health measures. For example, the incidence of premature death in the area, measured at 6,889 years lost annually per 100,000 people, was lower than the state’s estimate. However, preventable death nationwide resulted in fewer years lost compared to Anchorage. Both Anchorage residents and Alaskans statewide reported above-average alcohol consumption. Close to one in five people in Anchorage reported binge or heavy drinking, in line with the state proportion, but higher than the national proportion.

3. Lake Havasu City-Kingman, Arizona
> Pct. without health insurance: 18.2%
> Pct. food insecure: 17.3%
> Obesity rate: 26.6%
> 2014 unemployment rate: 8.8%

Lake Havasu is one of the widest points in the Colorado River, which separates Arizona from California. The city on the lake is about an hour drive from Kingman, which is also part of the metro area. While Arizona residents had relatively healthy habits, residents of the Lake Havasu-Kingman metro area were more likely to smoke and less likely to exercise than their peers across the state and nationwide. Less than 17% of Arizonans reported a smoking habit, while in the Lake Havasu area, 26.9% smoked. And while just over 20% of Arizona residents were physically inactive, 30.8% of the metro residents were, likely contributing to the higher obesity rate. Nearly 27% of area residents were obese, higher than the state’s obesity rate of 23.9%.

4. Pine Bluff, Arkansas
> Pct. without health insurance: 13.4%
> Pct. food insecure: 9.0%
> Obesity rate: 37.8%
> 2014 unemployment rate: 8.6%

Arkansas is one of the nation’s least healthy states. Partially as a result, Pine Bluff is not just the state’s least healthy metro area, but also one of the least healthy cities in the country. Only 57.6% of residents had adequate access to locations for physical activity, lower than the state share of 65.8% of residents, which itself was the fourth lowest compared to other states. The poor access likely contributed to Pine Bluff’s obesity rate of 37.8%, one of the highest of any U.S. area.

While Pine Bluff residents were more likely to have health insurance than both their statewide peers and Americans nationwide, practitioners are relatively scarce in Pine Bluff. There is one dentist for every 4,154 area residents, for example, far worse than the state ratio of one dentist for every 2,338 people, the worst ratio of all states. Similarly, there are roughly 1,749 people for every doctor in Pine Bluff, a worse ratio even than the already relatively poor state ratio.

5. Visalia-Porterville, California
> Pct. without health insurance: 19.4%
> Pct. food insecure: 8.1%
> Obesity rate: 28.3%
> 2014 unemployment rate: 13.2%

California residents had some of the nation’s healthiest behaviors as well as some of the best health outcomes, in contrast with the Visalia metro area — the state’s least healthy urban region. Nearly one in four area residents reported fair or poor health, versus the comparable state and national proportions of 18.4% and 16.0%, respectively. Lack of health insurance may have contributed to worse health outcomes in the area — health insurance is important not just because it reduces the economic burden on the sick, but also because it encourages people to get routine checkups. California had good health outcomes despite its relatively high uninsured rate of 17.2%, the eighth highest. The Visalia area had an even higher rate of 19.4%, significantly greater than the national uninsured rate of 14.5%.

6. Pueblo, Colorado
> Pct. without health insurance: 12.8%
> Pct. food insecure: 16.0%
> Obesity rate: 26.5%
> 2014 unemployment rate: 7.3%

Colorado had the nation’s lowest obesity rate and lowest rate of physical inactivity, at 15.2% and 20.4%, respectively. But while Pueblo, the state’s least healthy metro area, also reported some relatively strong health measures, it fared very poorly in others. For example, while Pueblo’s obesity rate of 26.5% was well above the state’s rate, it was still lower than the national rate of 28.3%. Yet, the incidence of premature death in the area was abysmal. An estimated 5,756 years are lost annually per 100,000 people in Colorado, versus the national figure of 6,622. In Pueblo, however, 8,686 years are lost annually per 100,000 area residents due to premature deaths.

7. New Haven-Milford, Connecticut
> Pct. without health insurance: 8.8%
> Pct. food insecure: 4.0%
> Obesity rate: 26.9%
> 2014 unemployment rate: 6.8%

Healthy behaviors and outcomes are closely associated with strong economic circumstances. Residents earning higher incomes can afford better health care, and those with higher levels of education often work in higher-paying jobs that also tend to lead to healthier lifestyles. Relatively high incomes in Connecticut largely explain the relatively strong health outcomes. And while 64.7% of New Haven area adults had completed at least some college — lower than the state share of 67% — it was still higher than the nationwide rate of 63%.

Thank you for reading! Have some feedback for us?
Contact the 24/7 Wall St. editorial team.