Special Report

Least Healthy City in Every State

Detailed Findings

In some of the healthiest states, even residents of the least healthy city are better off than the average American by a number of health metrics. In Hawaii, for example, an average of 276 in every 100,000 residents die before age 75 each year, the fourth lowest premature mortality rate of any state. While the Kahului-Wailuku-Lahaina metro area is the least healthy metro area in the state, its premature death rate of 275 per 100,000 is still far below the national rate of 336 premature deaths per 100,000 Americans. In 16 states the premature death rate in the least healthy city is still below the national figure.

Our findings show that the health behaviors that are most correlated with premature mortality at the metropolitan level are smoking, a lack of exercise, and obesity. Smokers are more than 25 times as likely to develop lung cancer than non-smokers, and are at a greater risk of dying prematurely. Additionally, adults who exercise seven hours a week are 40% less likely to die prematurely than those engaging in less than 30 minutes of exercise per week. In 49 of the 50 cities with the highest incidence of premature death, the share of adults who report no leisure-time physical activity is greater than the 23.0% national figure.

People earning higher incomes have greater access to health care, can better afford healthy food, and may have more time to exercise. Due to these and other factors, more affluent individuals have better health outcomes overall. In all 50 of the cities with the highest premature mortality rates nationwide, the typical household earns less than the national annual median household income of $57,617. Socioeconomic factors included in our index that are the most correlated with the premature mortality rate include median household income, the share of children living in single-parent households, the share of children living in poverty, and the food insecurity rate.


To determine the least healthy city in every state, 24/7 Wall St. created an index composed of 35 health outcomes and health factors with data from the 2018 County Health Rankings & Roadmaps, a joint program of the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute. County-level data was aggregated to the metropolitan statistical area level using five-year population estimates from the U.S. Census Bureau’s American Community Survey for 2011 to 2016. Health outcomes with the heaviest weights in the index include the age-adjusted premature mortality rate, the percentage of births with low birthweight, the percentage of adults reporting fair or poor health, and the average number of mentally and physically unhealthy days per month reported by the adult population. Health factors with the heaviest weights in the index include the smoking rate, the 2017 unemployment rate, and the child poverty rate.